Diabetes and Kidney Disease

http://www.kidney.org/

Diabetes mellitus, usually called diabetes, is a disease in which your body does not make enough insulin or cannot use normal amounts of insulin properly. Insulin is a hormone that regulates the amount of sugar in your blood. A high blood sugar level can cause problems in many parts of your body.

Are there different types of diabetes?
The most common ones are Type 1 and Type 2. Type 1 diabetes usually occurs in children. It is also called juvenile onset diabetes mellitus or insulin-dependent diabetes mellitus. In this type, your pancreas does not make enough insulin and you have to take insulin injections for the rest of your life.

Type 2 diabetes, which is more common, usually occurs in people over 40 and is called adult onset diabetes mellitus. It is also called non insulin-dependent diabetes mellitus. In Type 2, your pancreas makes insulin, but your body does not use it properly. The high blood sugar level often can be controlled by following a diet and/or taking medication, although some patients must take insulin. Type 2 diabetes is particularly prevalent among African Americans, American Indians, Latin Americans and Asian Americans.

What does diabetes do to the kidneys?
With diabetes, the small blood vessels in the body are injured. When the blood vessels in the kidneys are injured, your kidneys cannot clean your blood properly. Your body will retain more water and salt than it should, which can result in weight gain and ankle swelling. You may have protein in your urine. Also, waste materials will build up in your blood.

Diabetes also may cause damage to nerves in your body. This can cause difficulty in emptying your bladder. The pressure resulting from your full bladder can back up and injure the kidneys. Also, if urine remains in your bladder for a long time, you can develop an infection from the rapid growth of bacteria in urine that has a high sugar level.

How many diabetic patients will develop kidney disease?
About 30 percent of patients with Type 1 (juvenile onset) diabetes and 10 to 40 percent of those with Type 2 (adult onset) diabetes eventually will suffer from kidney failure.

What are the early signs of kidney disease in patients with diabetes?
The earliest sign of diabetic kidney disease is an increased excretion of albumin in the urine. This is present long before the usual tests done in your doctor's office show evidence of kidney disease, so it is important for you to have this test on a yearly basis. Weight gain and ankle swelling may occur. You will use the bathroom more at night. Your blood pressure may get too high. As a person with diabetes, you should have your blood, urine and blood pressure checked at least once a year. This will lead to better control of your disease and early treatment of high blood pressure and kidney disease. Maintaining control of your diabetes can lower your risk of developing severe kidney disease.

What are the late signs of kidney disease in patients with diabetes?
As your kidneys fail, your blood urea nitrogen (BUN) levels will rise as well as the level of creatinine in your blood. You may also experience nausea, vomiting, a loss of appetite, weakness, increasing fatigue, itching, muscle cramps (especially in your legs) and anemia (a low blood count). You may find you need less insulin. This is because diseased kidneys cause less breakdown of insulin. If you develop any of these signs, call your doctor.

TABLE 1
Signs of Kidney Disease in Patients with Diabetes

1. Albumin/protein in the urine
   
2. High blood pressure
   
3. Ankle and leg swelling, leg cramps
   
4. Going to the bathroom more often at night
   
5. High levels of BUN and creatinine in blood
   
6. Less need for insulin or antidiabetic medications
   
7. Morning sickness, nausea and vomiting
   
8. Weakness, paleness and anemia
   
9. Itching

What will happen if my kidneys have been damaged?
First, the doctor needs to find out if your diabetes has caused the injury. Other diseases can cause kidney damage. Your kidneys will work better and last longer if you:

• Control your diabetes
• Control high blood pressure
• Get treatment for urinary tract infections
• Correct any problems in your urinary system
• Avoid any medicines that may damage the kidneys (especially over-the-counter pain medications)

If no other problems are found, your doctor will try to keep your kidneys working as long as possible. The use of high blood pressure medicines called angiotensin converting enzyme (ACE) inhibitors has been shown to help slow the loss of kidney function.

How are the kidneys kept working as long as possible?
The kidney doctor, called a nephrologist, will plan your treatment with you, your family and your dietitian. Two things to keep in mind for keeping your kidneys healthy are controlling high blood pressure in conjunction with an ACE inhibitor and following your renal diabetic diet. Restricting protein in your diet also might be helpful. You and your dietitian can plan your diet together.

What is end stage renal failure in patients with diabetes?
End stage renal failure, or kidney failure, occurs when your kidneys are no longer able to support you in a reasonably healthy state, and dialysis or transplantation is needed. This happens when your kidneys function at only 10 to 15 percent. The usual span of time between the onset of diabetic kidney injury and kidney failure is about five to seven years.

How is kidney failure treated in diabetic patients?
Three types of treatment can be used once your kidneys have failed: kidney transplantation, hemodialysis and peritoneal dialysis.

Can a patient with diabetes have a kidney transplant?
Yes. Once you get a new kidney, you may need a higher dose of insulin. Your appetite will improve so your new kidney will break down insulin better than your injured one. You will use steroids to keep your body from rejecting your new kidney. If your new kidney fails, dialysis treatment can be started while you wait for another kidney.

What about pancreas transplants?
Sometimes it is possible to perform a pancreas transplant along with a kidney transplant. Your doctor can advise you about this possibility.

What about a low-protein diet?
Research suggests that a low-protein diet can slow the advance of kidney damage.

What is the future outlook for patients with diabetes?
Today, more and more research dollars are spent on diabetes research. Hopefully, the prevention and cure of diabetes is in our future. In the meantime, you can manage your diabetes better with:

• home monitoring of your blood glucose levels
• maintaining an awareness of controlling your blood pressure, and possibly monitoring your pressure at home
• following your special diet.

Source : http://www.kidney.org/ATOZ/atozItem.cfm?id=37

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What is ANGIOGRAM / ANGIOPLASTY ?

• What is an angiogram ?
• Preparation for the angiogram
• During the angiogram
• After the angiogram
• When do I know the angiogram result ?
• What is an Angioplasty ?
• During the angioplasty
• After the angioplasty
• What are the possible side effects/complications ?
• Can I do anything to help myself ?
• How effective is angioplasty ?

ANGIOGRAM

What is an angiogram ?

The picture below is an angiogram of the blood vessels around the hip joint. An angiogram is a special form of x-ray that permits the diagnosis of blockages (occlusions) or narrowings (stenosis) in the arteries of the body. During the test, a tube (catheter) is inserted into an artery at the groin. A special radio-opaque dye (contrast medium) is injected down the tube and x-ray pictures are taken as the solution passes along the blood vessels. The whole procedure usually lasts approximately one hour. The arteries take blood from the heart to supply oxygen to muscles and organs and the angiogram will tell your doctor if the supply of blood is being affected. The procedure is performed by a specialist interventional radiologist or a vascular surgeon.

Preparation for the angiogram

You will normally be admitted to the ward for a few hours beforehand to check out your general health and to prepare you for the angiogram. On the day of the test you may eat and drink as normal although this may vary between hospitals. If you take regular medications you should take your usual morning doses. The only exception to this might be if you are taking warfarin, in which case you should follow instructions provided for you. Frequently warfarin is stopped before an angiogram, but not always. If you have diabetes and inject insulin you should have your normal food and insulin dose, unless instructed not to. On arrival, you will be seen briefly by the doctor, the test will be explained to you and you will be asked to sign a consent form. This is to ensure you understand the test and its implications. Please tell the doctor if you have had any allergies or bad reactions to drugs or other tests. It would also be helpful to mention to the doctor if you have asthma, hay fever, diabetes, or any heart or kidney problems. Kidney problems can be particularly important.

This is because the dye used to outline the arteries can damage the kidneys if special precautions are not taken. If you have any worries or queries at this stage don't be afraid to ask. The staff will want you to be as relaxed as possible for the test and will not mind answering your queries. You will be asked to put on a hospital gown. The test will take place in the x-ray department, a nurse will escort you and stay with you during the test. A small drip will be placed into a vein in the arm or hand during the procedure. This may be used to give intravenous fluids. It may be necessary to trim some of the hair from the groin area before the test to help skin cleaning.

During the angiogram

The radiologist (x-ray doctor) will inject a local anaesthetic into the skin at the groin "freezing" the area. After this injection the procedure should be fairly painless. The long fine tube (catheter) is then inserted into the artery at the groin (common femoral artery), and using x-rays to help, the radiologist manipulates the catheter into the correct position. You will not feel the catheter being moved around your body. X-ray pictures are taken whilst the dye is injected down the catheter into the blood vessels. To be able to take pictures along a length of arteries, the radiologist will move the bed so that different portions of the arteries can be examined.

Some injections may cause hot flushing for a few seconds, and an occasional feeling of wanting to pass urine. When the test is completed the catheter is removed and pressure will be applied to the groin for approximately ten minutes to minimise any bruising.

After the angiogram

You will be taken back to the ward to rest for a few hours. It is important that you lie quietly so that the groin does not bleed again. The nursing staff will check the groin, and foot pulses at regular intervals. If no pulses are present the colour and temperature of the foot is important. Providing all is well, you will be allowed home, but you need someone with transport to take you home, or to accompany you in a taxi. It is important that you rest completely until the next day to ensure that the puncture site in the groin heals up. If after you get home you notice any swelling or bleeding at the puncture site, you should press on this and call your GP's surgery for advice.

When do I know the angiogram result ?

The radiologist and vascular surgeon will look at the x-ray pictures and discuss their findings. They will decide the best form of treatment for you and then write to you, or see you again in the outpatient clinic. The treatment can then be discussed and as always it is the patient who decides whether to proceed with treatment or not.

ANGIOPLASTY

What is an Angioplasty ?

An angioplasty is a procedure where a balloon is passed into your artery on the end of a tube (catheter) and is inflated (blown up) to treat a narrowed or blocked artery. This technique means that surgery may be avoided in many cases. There are two techniques for performing angioplasty - transluminal and subintimal. In the transluminal technique the balloon is placed in the centre of the artery (in the lumen) where blood would normally flow. In subintimal angioplasty the balloon is intentionally placed within the layers of the arterial wall. As far as the patient is concerned, angioplasty is very similar to an angiogram except that a slightly bigger catheter is used and therefore the risks of bleeding are slightly greater. For this reason, in most cases, you will be asked to stay overnight. You will usually be asked to start taking aspirin before you are admitted as this makes the blood less sticky. A common dose is 75 mg per day. If you have a stomach ulcer or are allergic to aspirin, please tell your doctor. The angiogram opposite shows the artery on the left before angioplasty and on the right following angioplasty.

During the angioplasty

Angioplasty takes a little longer than simple angiography and you may feel the doctor changing, and pushing, catheters in and out of your groin artery. Although this is occasionally a little uncomfortable, it is not usually too painful. Sometimes, it will be necessary to insert a special device called a stent to keep the artery open. This is just a small metal tube that expands in your artery to keep the area open and allow more blood to flow through. Stents appear to be especially useful in larger arteries above the level of the hip joints. They can be used in arteries in the thigh but results are mixed. A recent trial (RESILIENT) compared a newer stent (the LifeStent) against angioplasty alone in the arteries in the thigh. Early results indicate that the stent maintains patency of the artery in the thigh at least for the first 12 months, despite nine stents fracturing. Only longer term published results will tell us whether this translates into longer term clinical benefit.

After the angioplasty

In some cases Heparin injections (anticoagulation) will be given for 24 hours to prevent the blood clotting at the site of the angioplasty. Rarely you may require warfarin tablets to thin the blood for a few months. You will normally be allowed home the following day. If you are given heparin or warfarin this may delay your departure by a few days. You will be seen again in the clinic by your surgeon to assess the success of the angioplasty and to decide upon any further treatments. Unfortunately, in about 10% of cases, angioplasty is not successful and other treatments will need to be considered. In addition, even where successful angioplasty has been performed, there is a risk that the area in the artery will narrow down again. After one year, about 20-30% of arteries will have re-narrowed. In some cases, it may be possible to repeat the angioplasty at that time although in others this may not be possible. Very rarely, if angioplasty does not work, the circulation may actually worsen. If this is a particular risk in your case, your surgeon and /or radiologist will discuss the risks with you.

What are the possible side effects/complications ?

Bleeding – a small amount of bleeding sometimes occurs when the catheter is removed. Before the procedure is finished, the radiologist will ensure, by pressing on the artery that all bleeding has completely stopped. Occasionally this bleeding can cause a small lump around the groin and commonly causes some bruising in the skin for a few days after the procedure. This is normal and will clear up on its own. Serious bleeding is very uncommon.

False aneurysm - rarely a pulsating lump develops in the groin at the site where the catheter was inserted into the artery. This is because bleeding took place after the catheter was removed. The clot produced forms a small sac with liquid blood in the centre. This blood pulses because it is connected to the artery through the hole made by the catheter. The sac with blood in the centre is called a false aneurysm. These days this problem can usually be treated by a simple injection into the sac to make the liquid blood in the centre form a clot and block the small hole in the artery.

Pain/Discomfort – local anaesthetic is injected into the skin just before the catheter is placed into the artery. This should take away any severe pain, but it is likely you may feel some gentle pushing and pulling during the procedure. The blood vessels themselves do not feel the guiding wire or catheter. Injecting the dye sometimes causes a sensation of warmth, but this usually lasts only a few seconds. Reactions to the dye – Reactions to modern dyes apart from the sensation of warmth are very uncommon. Various reactions and allergies can still occur and the staffs are fully trained and equipped to deal with any reaction which may occur. Reactions may include skin rashes, vomiting, asthma, low blood pressure and disturbances of heart beat and kidney damage. Damage to blood vessels – this can occur during angioplasty especially if the artery is already badly diseased. The catheter may make a hole in the blood vessel or strip the lining from the blood vessel.

Usually these problems can be dealt with by the radiologist at the time of the procedure. If it is not possible to deal with the problem in radiology then an operation may be required. Nerve effects– sometimes the local anaesthetic can numb main nerves in the front of the thigh, causing numbness going down the leg and weakness. This will wear off after an hour or so. Equipment failure – it is theoretically possible for the catheter or its guiding wire to break and leave a fragment inside the body. Procedures are available to deal with this eventuality in the radiology department but occasionally surgery may be required. Failure of technique – occasionally it is not possible to perform the angioplasty. This may be because the artery is too diseased. Sometimes inserting a metal stent to hold the artery open can be helpful, especially for larger arteries in the pelvis. Blood clots – blood clots can form at the angioplasty site within the artery. These can usually be dealt with by using enzymes that dissolve the lot, but can sometimes be a problem which can cause the circulation to deteriorate.

Kidney damage - Damage can occur to cells in the kidney during an angiogram. This can lead to a deterioration in kidney function if your kidneys are already diseased. The cause of the damage is the special radio-opaque dye that is injected into the arteries so that they can be seen with X-rays. Although other dyes are available (gadolinium) they are probably no safer than conventional dyes. If the doctors know your kidneys may be at risk during an angiogram, they can reduce the risks of damage by giving extra fluids in an intravenous drip before during and after your angiogram.

Can I do anything to help myself?
You cannot do anything to relieve the actual narrowing in your arteries. However, you can improve your general health by taking regular exercise, stopping smoking and reducing the fat in your diet. Your blood pressure should also be measured and kept under control. These actions will help slow down the hardening of the arteries which caused the problem in the first place, and may avoid the need for further treatment in the future.

How effective is angioplasty?
The effectiveness of angioplasty depends on exactly which type of angioplasty is performed. In general if the artery is only narrowed, and has not totally blocked, then angioplasty is more likely to be successful and any improvement is likely to last longer. If the length of artery to be treated is short (less than 5cms), then angioplasty is likely to be more successful than if a much longer length of artery is diseased and requires treatment. Angioplasty is more likely to be successful in a large artery (iliac arteries in pelvis) versus a small artery (tibial arteries in calf). A 1 cm long narrowing in a large iliac artery (in the pelvis) supplying the leg, treated by angioplasty is likely to produce a very good result. In contrast a 10cms blockage in a tibial artery in the calf may be very tricky to treat by angioplasty.

Overall angioplasty is technically successful in 90-100% of patients, but the late results can be less impressive. For short arterial occlusions in the thigh the angioplasty site can remain open in 60-80% of patients, but the effect on symptoms is frequently poorly investigated. In less suitable arterial disease the benefits of angioplasty may be considerably less. In a study reporting the results of subintimal angioplasty for severe arterial disease in the legs only 25% (25 in 100) of the arteries were still open at 12 months and results were poorer when segments of artery greater than 10cms long were treated (Smith BM et al, 2005).A recent study (BASIL, 2005) has compared angioplasty with bypass surgery in patients with severe limb ischaemia (see bypass surgery).

In patients who are suitable for both angioplasty and bypass surgery, an angioplasty first strategy had broadly similar outcomes to surgery. Unfortunately, the majority of patients presenting with severe disease (approximately 80%) are not suitable for both strategies and are more likely to require surgery. In general vascular specialists will attempt angioplasty first in place of surgery if there is a reasonable chance of a good outcome. If this fails bypass surgery is still likely to be an option. In the USA, since 1996, there has been a 40% increase in the use of angioplasty in the leg arteries and a 30% decline in open bypass surgery (Nowygrod, 2006).

Source: http://www.vascular.co.nz/angiogram.htm

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Cardiovascular risk in Diabetes

Exercise can reduce your risk of stroke and heart disease.

What is cardiovascular disease?

Exercise can reduce your risk of stroke and heart disease.
‘Cardio’ means to do with the heart and ‘vascular’ to do with the blood vessels. ‘Cardiovascular’ means the heart and circulation. Diseases of the circulation are caused by hardening of the arteries, and are common in Western society.

They are:

• angina (chest pains)
• heart disease
• heart attacks (when blood supply is cut to the heart)
• stroke (when blood supply is cut to the brain)
• poor circulation to the legs.

Atherosclerosis (hardening of the arteries)

Atherosclerosis is the underlying process that leads to cardiovascular disease. Arteries are the blood vessels that lead away from the heart and which deliver oxygen-rich blood to the tissues of the body.They are essentially tubes of muscle with a special interior lining of cells that ensures blood flows along smoothly.When affected by atherosclerosis, diseased arteries become substantially narrowed by thickening of the muscle layer and in particular by a fatty deposit (plaque) that builds up under the lining.

Plaque in arteries is a mixture of:

• fats, particularly cholesterol
• a build up of cells from the body’s immune system
• proteins like those that form in a scar.

A plaque starts off small but with time it gets bigger, steadily narrowing the artery at this point.

As well as obstructing blood flow, a plaque is also a weak point in an artery. The thin covering of the plaque can rupture, exposing it and the underlying muscular layer of the artery.

This can trigger a sequence of reactions that results in the blood clotting at the site of the plaque rupture. Suddenly what had been a narrowed artery can turn into a completely blocked one.

This is very often what happens in a stroke - or a heart attack if it occurs inside one of the heart’s arteries rather than the brain.

What are the risk factors for cardiovascular disease?

The UK has one of the worst records in the world for cardiovascular disease because of factors such as:

• high fat diet
• a tendency to eat lots of salt which raises blood pressure
• low levels of exercise
• the effect of smoking.

Diabetes and cardiovascular risk

Diabetes increases the risk of cardiovascular disease by as much as four times.
While blood sugar control is still important, you also need to tackle the other risk factors such as obesity.

The most important risk factors that affect your chances of getting a cardiovascular disease are:

• diabetes
• smoking
• high blood pressure (hypertension)
• raised blood fat (lipid) levels - mainly cholesterol and triglyceride
• excess body weight

Calculating risk

A great deal of information has been built up about what effects the various cardiovascular risk factors such as age, smoking, high blood pressure etc have on an individual’s long-term health.

This has led to the concept of quantifying risk. Most of these calculators attempt to put a figure against your eventual likelihood of having a major cardiovascular event (heart attack, stroke).

This is usually stated as a percentage likelihood of an event occurring within a certain time span.

Doctors divide risk into:

• low: less than 15 per cent chance of an event in the next 10 years
• medium: 15-30 per cent chance in the next 10 years
• high: more than 30 per cent chance in the next 10 years.

What are the pros and cons of risk calculators?

On the positive side they can allow people at the highest risk to receive the most medical attention that will improve their health.In recent years this has resulted in prescribing guidance for doctors that states which risk group of patients can receive certain types of drugs.On the downside, many doctors feel that categorising people this way is too simple.Many people within the ‘lower risk’ categories would still benefit from receiving certain types of treatment. This has been well shown in the case of statin statin treatment to lower cholesterol levels in diabetes.

How can they help me?

You can use risk calculators to help you see the impact of making changes.

Risk calculation shouldn't be taken as fact. Many of the ways we currently assess risk will probably be shown to be inaccurate in the future, but they are the best we presently have.

As always, the important actions we can all take are those that follow the lines of healthy living.

Source: http://www.netdoctor.co.uk/diabetes/index.shtml