Sometimes, despite your best efforts, damages to your kidney worsens. Your condition may progress to the point where your kidneys are no longer able to filter toxins from the blood and cannot keep protein from spilling over into the urine. When this happens, you may have renal insufficiency. This stage of nephropathy is also called clinical nephropathy or kidney failure.
Damage to the kidneys at this stage cannot be reversed by simple preventive measures such as lowering blood pressure and controlling blood glucose. However, paying attention to the same lifestyle factors can slow disease progression. At every stage of kidney disease, it is important to control your blood pressure, blood glucose levels and diet to minimize further damage to your kidneys. You may feel like giving up, but this is the last thing you should do. Even at this stage, treatments are available that can add years to your life.
When your kidneys are working less than 30% of their normal capacity, you may begin to feel more of the symptoms of kidney disease. You might feel listless, lose your appetite, find it difficult to concentrate, feel cold, experience bouts of nausea, and your skin may feel unusually itchy. When your kidneys begin to function at less than 15%, you may notice that your skin bruises easily and you may lose weight without trying. You may vomit intermittently and experience lethargy and restless legs. You may also feel sleepy or unnaturally drowsy during the day but find it difficult to sleep at night. If you take insulin, you may need less, because less insulin is passing through your kidneys. Clinically, your doctor may also detect anemia, or low iron.
What You Should Do
If you notice any change in your general state of health or notice any change in your symptoms or new symptoms developing, talk to your doctor. You should be seeing your doctor regularly. Your doctor will routinely examine you and conduct tests to keep tabs on your kidney function. As your kidneys begin to fail, they do a poorer job of filtering impurities and toxins from the blood. Your doctor can get an idea of how your kidneys function by measuring the levels of some of these impurities in the blood. One test, called a BUN, measures the amount of nitrogen in the form of urea that is in the blood. Urea is a breakdown product of protein degradation.
You probably will also be tested for the amount of creatinine, another metabolic waste product, in your blood or serum. When your serum creatinine levels rise above 2.0mg/dl, you may be referred to a nephrologist, a doctor who specializes in kidneys. At this point, you, your doctor, and your nephrologist may want to come up with a more aggressive treatment plan.
You and your doctor will want to take several factors into account in developing a treatment or management plan at this stage. In general, you will want to identify and eliminate anything that may be damaging your kidneys, such as a drug or lifestyle factor.
You will also want to continue to keep your blood pressure, blood glucose, metabolic factors, and diet under control to keep your kidney functioning as efficiently as possible. You may need to reevaluate your blood pressure medication and other drugs you may be taking. Some drugs, including several blood pressure medications, can cause damage to the liver. You and your doctor will want to discuss the pros and cons of any such drug.
Your doctor may also recommend a diet that is low in protein. Several studies have shown that a diet containing no more than 40 to 60 grams of protein each day slows the loss of kidney function. You and your doctor may also want to reevaluate your blood glucose goals. Once your kidneys have begun to fail, it may not do that much good to maintain an intensive therapy program. If you are practicing tight control, you may face a higher risk of hypoglycemia without the benefit of preventing kidney damage. Therefore, you and your doctor should discuss whether tight control is a prudent goal.
Because the kidney produces many hormones that affect your electrolyte balance, damage to the kidney can disturb your overall metabolism. For example, potassium and salt levels may become unbalanced. Some patients may retain excessively high levels of salt and/or potassium, while others may lose large amounts of salt from the body.
Your doctor will monitor the levels of salt and other metabolites and may recommend dietary or drug therapy to keep your metabolites in balance. Improper balance of salts and electrolytes can stress the cardiovascular system and can lead to cardiac arrest.
At this point, you and your doctor should also discuss the possibility of future therapy. As kidney damage progresses, you may eventually face the decision of electing a kidney transplant of dialysis. You and your doctor should talk about the pros and cons of these major therapeutic interventions. You may continue for several years in a state of renal insufficiency but should prepare yourself for what to do when you reach end-stage renal disease.
Eventually, your kidney may become damaged so much that they can no longer function. When this happens, you have end-stage renal disease. If left untreated, your kidneys will be unable to filter your blood adequately. Metabolic wastes, such as urea and creatinine, as well as salts and electrolytes can rise to toxic levels. Fluid can accumulate in all the tissues of your body, including the sack that surrounds your heart. This makes it increasingly difficult for your heart to pump blood. At this point, to continue living, you need to turn to dialysis or kidney transplant.
Symptoms of end-stage renal disease include edema, or swelling, in the extremities, particularly the ankles, and in the face, especially around the eyes. Fluid accumulation around the heart and lungs may make you especially tired and short of breath. Even simple tasks may become difficult. You may also have muscle cramps, especially in the digestive tract, which can lead to nausea and vomiting. The bowel can become bloated and sometimes gastrointestinal ulcers develop. Skin can take on an orange-yellow color and muscle and fat may begin to waste away. People with end-stage renal disease often notice blood in their urine. Sleeping patterns may also be disturbed. Neurological symptoms, including convulsions and seizures, can also occur.
What You Should Do
You should be visiting your doctor regularly. During your visits, your doctor may run some tests to monitor your kidney function. If you experience any worsening of symptoms, any new symptoms, or a general change in how you feel, make sure to tell your doctor right away. Once you develop end-stage renal disease, you need a more aggressive treatment.
If you have end-stage renal disease, you need a treatment that will do the job of filtering impurities from your blood, because your kidneys can no longer perform this function. Currently, three treatment options are available: hemodialysis, peritoneal dialysis and a kidney transplant.
Dialysis is a way of removing the waste products and toxins from your blood without getting rid of the blood cells that you need. With hemodialysis, your blood flows from your arm, through a machine that purifies your blood, and then back into your arm to our bloodstream. With peritoneal dialysis, a solution is put into your abdominal cavity and drained at regular intervals. This solution, known as a dialysate, removes the impurities from your blood.
Eighty percent of all patients with end-stage renal disease are treated with hemodialysis. If you decide on this treatment, you will most likely visit a dialysis center or clinic three times a week. You will be hooked up to the machine, which functions as an artificial kidney, for 4 to 6 hours during each visit. The disadvantages of hemodialysis are the time commitment and expense, the risk of clotting at the access point (the site at which blood is removed and returned to the body) and the possibility of hemorrhage and infection. Usually, patients undergoing hemodialysis must take an anti-clotting drug, such as heparin. About 80% of all patients treated by hemodialysis survive the first year of treatment.
Peritoneal dialysis is another method of cleansing the blood through dialysis. The most common method of peritoneal dialysis is called constant ambulatory peritoneal dialysis. It performs the same function as hemodialysis. But instead of removing blood from the body and cleansing it in a machine, you infuse a solution of dialysate into the peritoneal cavity, your abdominal cavity. There blood from the blood vessels that line the cavity is diluted by the dialysate. The impurities remain in the dialysate in your abdomen while the clean blood moves on to the rest of the body. You then drain the dialysate and remove the impurities from your body. This procedure is repeated every 4 to 6 hours. Your abdomen, in essence, acts as an artificial kidney to clean the blood from your body.
There are several advantages to peritoneal dialysis. You don’t have to visit a hospital or clinic as often and are not hooked up to a machine for long periods of time. You can perform the treatment yourself. Also, you don’t need to take heparin or another anti-clotting drug. This treatment appears to provide the best hope for rehabilitation and promotes the longest survival rate of any dialysis technique.
However, it requires a high degree of patient motivation. The technique also has its disadvantages. You have to pay constant attention to fluid exchange and are at risk of peritonitis, an infection of the lining of the stomach.
By far, the most successful treatment for end-stage renal disease is kidney transplant. During this procedure, your kidney is removed and replaced with a healthy kidney from a living donor, usually a relative or friend, or someone who has recently died. Usually, people who have kidney transplants are able to completely renew the activities they enjoyed before developing nephropathy.
The biggest disadvantage of kidney transplant is the threat of rejection of the new kidney by your immune system. Your immune system will see a new kidney as a foreign invader and try to get rid of it. You will be given drugs that suppress the immune system to let your new kidney survive and do its job. Unfortunately, these drugs are toxic and can cause damage to the kidney.
More than 90% of people who get a new kidney survive the first year. This is a greater success rate than dialysis. 20% of people who elect transplants survive more than 10 years. Transplants are highly recommended if you are newly diagnosed with diabetes and end-stage renal disease and if you are under the age of 60.
Many people with type 1 diabetes who decide to have a kidney transplant also elect to have a pancreas transplant done at the same time. This is because the major disadvantage of any transplant is the immune suppressive drugs that must be taken. But if you are taking them anyway for a kidney transplant, it may make sense to have a pancreas transplant done also. You reap a greater benefit for the same risk.
Make sure to discuss the pros and cons of each treatment with your doctor well before the point at which you need immediate attention. Finding a donor may take time, and it helps to plan ahead, before your condition becomes critical. Often patients awaiting transplants will go on dialysis until an organ becomes available.
Sources and References
The Diabetes Problem Solver—Quick Answers to Your Questions About Treatment and Self-Care by Nancy Touchette
Diabetes, Heart Failure, and Renal Dysfunction: The Vicious cCrcles by Eugene Braunwald
Diagnosis and Management of Type 2 Diabetic Kidney Disease by Simit Doshi and Allon Friedman
Perioperative Management of Patients with End-Stage Renal Disease by Yuji Hirasaki, Takafumi Takayuki Kunisawa et al