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.

 

REMEMBERING PROF. K. D. VERMA AND PROF. N. S. BHATNAGAR - AN IDEAL SURGEON - ANAESTHETIST RELATIONSHIP

 

These two friends were inseparable and there is no way I can remember one without the other. Prof. K. D. Verma was a Reader in the Department of Surgeryand Prof. N.S. Bhatnagar was a Reader in the Department of Anaesthesia  in King George's Medical College,  Lucknow when we were doing our MBBS and MS. They offered the perfect example of cordiality that should exist between a surgeon and an anesthetist. I have learned this from these two teachers and have discussed it in great details in one of my previous blogs. If you want to read it, please click: https://surajitbrainwaves.blogspot.com/2019/12/never-argue-with-anaesthetiest.html

 

Prof. Verma was tall, dark and handsome, extremely helpful and always smiling and an very good teacher. His lectures were carefully designed and always to the point. He knew exactly how long to spend on a given point, and he never seemed to rush to the conclusion.  Yet he always had ample time to finish and then ask a few pertinent questions, just to ensure that the subject was clear in our minds.

 

Dr. Verma was trained in Endocrine Surgery from U.K. and was a pioneer thyroid surgeon of our State of Uttar Pradesh, a state which always had a population greater than Europe! So, not only was his Medical College OPD always overflowing with cases of goitre and thyroid cancer, but even his private practice was very busy, predominantly with Thyroid patients. Lucknow being close to the Tarai region of the Himalayas, where iodine deficiency was an endemic then, there was no dearth of goiter patients during our training days.

 

I never had an opportunity to work in Prof. K. D. Verma's unit and so naturally I had not seen and assisted so many thyroid cases as my friends who had worked with him had. But, all that was about to change.

 

After completing my M.Ch in Plastic Surgery and overseas training in four continents, when I returned to Lucknow to start my own practice, I did so in Neera Hospital where Prof. K. D. Verma would regularly operate most of his private cases. He was usually assisted by my two very respected seniors, Dr. Ramakant, who later retired as the Professor and HOD of Surgery and became the President of Association of Surgeons of India and Dr. Ajit Jafa, a senior surgeon doing exclusive private practice in Lucknow then. 

 

One day Prof. Ramakant was held up and Dr. Jafa was out of town. I had just finished my Cleft Palate repair and I did not realize that Prof. Verma was standing behind me, watching me operate. He was very kind with his words of appreciation for my surgery, but little did I know that my luck had struck gold! He asked me if I was free and would I help him with his sub-total thyroidectomy!

 

This started a beautiful relationship of the true Guru-Shishya parampara, and after that I had the privilege of assisting him countless times. What this meant was that an umbra region in my surgical training was suddenly and unexpectedly illuminated by the best guiding light in the world!

 

Right from anaesthesia after seeing the vocal cord movements and documenting it, to positioning the patient's head, neck and shoulders to marking the incision along a horizontal skin crease in the neck with a thread every step was meticulously done in every thyroid surgery.

 

I learned the steps by seeing him methodically follow them again and again. With his original assistants he would never be so verbose, but with me the teacher in him realized that this surgical field was not the one I would often visit. So, he made it a point to explain every step and show every structure.

 

A typical thyroid surgery, a sub-total thyroidectomy will go thus:

• Incision and Exposure: A transverse incision was made in a lower neck skin crease, followed by raising subplatysmal flaps to access the strap muscles.
• Accessing the Thyroid: The strap muscles (sternohyoid/sternothyroid) were separated at the midline and retracted to expose the thyroid gland.
• Ligation of Vessels: The superior pole vessels were ligated first, close to the gland, followed by the middle thyroid vein and then branches of the inferior thyroid artery, often using energy devices or sutures, away from the gland.
• Identification of Structures: The recurrent laryngeal nerve (for voice) and parathyroid glands (for calcium regulation) were carefully identified and preserved.
• Subtotal Excision: Removal of majority of the lobes, leaving a small remnant of tissue on the posterior aspect of the gland to avoid damaging the nerves and parathyroids.
• Closure: Hemostasis was confirmed, and the incision was closed in two lavers with sutures, sometimes placing a surgical drain temporarily, to be removed after 48 hours.

Post operatively the anesthetist, Prof. Narayan Swaroop Bhatnagar would once again confirm the movements of the vocal cords and then the patient was wheeled out.

 

Near the superior pole of thyroid, Prof. Verma would caution me that the Superior Thyroid artery and the external branch of Superior Laryngeal Nerve (EBSLN) travel close together but diverge as they approach the thyroid. So, this artery should be ligated close to the gland, almost abutting it as ligating higher up may damage the EBSLN. This will result in inability to reach high pitched notes.

 

Again, Prof. Verma was most careful while ligating the Inferior Thyroid Artery because of the close approximity of Recurrent Laryngeal Nerve (RLN) and the anatomical variations that can be in their relationship. He would follow the artery to its intersection with the nerve, identify and preserve the latter, and ligate individual arterial branches directly on thyroid capsule, away from the gland. This protected both the RLN and the blood supply to parathyroids that prevented ischemia of parathyroid and resultant hypocalcaemia.  

Once, when I asked how we can diagnose hypocalcaemia he explained:

Low calcium levels cause neuromuscular excitability, leading to:

• Early Signs: Paresthesia (numbness and tingling) in the fingertips and around the mouth.
• Progressive Signs: Muscle cramps, stiffness, and irritability.
• Severe Symptoms: Tetany (sustained muscle contraction), seizures, laryngospasm, and life-threatening cardiac arrhythmias.  

He then went on to explain two tests of hypocalcaemia

- Chvostek’s sign (facial twitching) 

- Trousseau’s sign (hand spasm with blood pressure cuff inflation).

 

Assisting Prof. K. D. Verma was fun. After every surgery there used to be a party, and Dr. N.K. Gupta, who was the owner of Neera Hospital, ensured that food and beverages were never in short supply! Tea, coffee, jalzeera, samosa, bun-makkhan, French toast, cake, pastries, ice-cream, all we had to do was name it……and it was there!

 

Prof. Verma and his anesthetist, Prof. N. S. Bhatnagar shared a unique bond of camaraderie. Their friendship was from their student days and they would unhesitatingly divulge each other's darkest secrets. There are countless stories that come to my mind. The most interesting story, narrated by Prof. Bhatnagar surely was the story of Prof. K. D. Verma's wedding.

 

He was married in a village in Madhya Pradesh, in the once notorious Chambal ravines, famous for dacoits, where no state police ever dared to enter. After the marriage, when he was returning with his newly wedded wife and the baratis, Prof. Bhatnagar being one of them, suddenly they saw a pile of dust in the horizon and heard the hooves of countless horses, getting louder and louder with every passing second. Soon from every direction masked horsemen were descending down the hill and appearing through the ravines. They surrounded the baratis and the newly weds. Everyone was convinced that this was a dacoity and not only will they lose everything, but would be distinctly lucky to escape alive from this mess.

The leader of the pack roared loudly and wanted to know who they were, who was the groom and who the bride's father was? Once he had all the answers he said that they can't go any further and have to accompany them to their Sardar's abode. Left with no choice they all agreed and their convoy was surrounded by all sides by masked horsemen as they made their way through the ravines. At one point they were asked to leave their vehicle, and around 20 horses were provided to them. Needless to say that most of them were on a horseback for the first time, but they were so scared that no one complained. Mercifully the animals did not gallop, they gently trotted and after some time, which seemed to be an eternity, they reached a beautifully decorated house, nestled in the ravines.

 

A huge man, with bushy handle bar moustache was waiting for them at the floral gate. He introduced himself as Malkhan Singh and took them all inside his house where his wife was waiting with an Aarti thali, flowers, sandalwood paste, dhoob and sweets. The bride and the groom were given new clothes to wear. The bride was decorated with sandalwood paste and new set of gold ornaments and the marriage ceremony was again performed. Gifts were showered not only on the groom but on every barati. Gun salutes were given to them and all the masked men danced in gay abandon. Later they were escorted back to their vehicles on horseback. The hosts had refilled their fuel tanks and they came all the way to the national highway to bid farewell to their daughter.

 

Dr. Bhatnagar in his inimitable style said, this was the famous Dacoit of Chambal, Daku Malkhan Singh, who was the bride's tau or bare papa (father's elder brother, not necessarily real brother but even a village elder is tau), and the message to the groom was loud and clear "you are taking my daughter with you, I must never hear any complaints from her!" Then with a triumphant smile he said "Now you know why K.D is so henpecked!" Prof. Verma, to his credit, was a perfect sport and would hit back with an equally interesting story of his own!

 

Dr. Bhatnagar was full of stories, one for almost every occasion and every surgeon. He could keep the atmosphere lively. He was my father's friend but that didn't spare me too. Once he told Prof. I. D. Sharma, with whom I often did breast surgeries, "Let him only reconstruct. Do the mastectomy yourself, don't leave it to him. His 'safe margins' will extend to your next patient." 

 

Prof. Bhatnagar belonged to Banda in Uttar Pradesh and his father was a doctor. My father worked for the Life Insurance Corporation of India, and was posted in Banda. Prof. Bhatnagar's father, Dr. Subbasi Lal, was our family physician and he and his wife treated my parents like their own children. That made me their favorite grandchild, and I remember milking a cow for the first time with Dadi, Prof. Bhatnagar’s mother! Prof. N. S. Bhatnagar and his brother Dr. I. S. Bhatnagar were very friendly with my father and they would often tease me "How will you do plastic surgery, you don't even know how to milk a cow properly. Most of the milk will be all over your face, instead of the bucket!" Prof. Bhatnagar stayed in Mahanagar on Mandir Marg next to the Mayor of Lucknow, Dr. S,C. Rai, a surgeon with whom he regularly operated.

 

Dr. K. D. Verma belonged to a very illustrious academic family. His sister, Prof. Roop Rekha Verma taught Philosophy in Lucknow University for four decades and became the Vice Chancellor of Lucknow University. Prof. K.D. Verma used to stay in Bishop Rocky Street and his house was home to many pet animals and birds. He was a true animal lover and dogs, cats, rabbits, ducks, birds of many variety, roosters and hens and even a pair deer were there.  He was a wonderful host during Holi and he and Mrs. Verma were present in all social gatherings. The couple graced both my wedding and my son's wedding. 

 

Later in life he developed vitiligo and the supremely confident role model that he was, he neither complained nor bothered. After his retirement from this teaching job in KGMC, his practice accelerated. His patients and his students loved him. His seniors too respected his knowledge and skill, and when Prof. P. C. Dubey wanted to get his thyroid cancer operated, he chose Prof. K. D. Verma as his surgeon.

 

We lost Prof. K. D. Verma to COVID. This was an irreparable loss to us, his students and most certainly to his patients. I, being a Plastic Surgeon, never operate on thyroid but because of the blessings of Prof. K. D. Verma, have helped many of my junior colleagues when they needed help in their thyroid surgeries.