Chronic Kidney Disease: The Hidden Complication
By Andrew Briskin
Chronic kidney disease (CKD) is one of the most common diabetes-related complications, but its silence, both within the individual and in conversations about diabetes, leaves millions unaware of how to act. Hear from experts at diaTribe’s latest Musings panel on diabetes and CKD, who hope to make more noise about the causes, treatments, and the importance of getting screened for CKD.
Chronic kidney disease (CKD), sometimes referred to as diabetic kidney disease when it occurs in someone with diabetes, is quite common among the diabetes population. In fact, it is estimated that as many as 40% of people with diabetes will develop CKD within their lifetime. Perhaps more alarming, however, is the number of people who are unaware that they are at risk for kidney disease, simply because the topic has never been brought up in a healthcare appointment.
Researchers continue to work toward pinpointing the causes of CKD and its link to diabetes. While there is still no cure, we can detect, prevent, and stop the progression of this complication.
Experts and advocates in diabetes and CKD discussed this and more at diaTribe’s Musings panel: “Uncomplicating Diabetes: What to Know About Your Kidneys.” You can watch the full panel discussion here.
Detecting CKD: Do it early!
The panelists agreed that the key to preventing CKD is for people with diabetes to discuss it early with their health care providers and get screened.
“One of the most important insights we’ve had about diabetes is that kidney damage starts early and is silent,” said Dr. James Gavin, clinical professor of medicine at Emory University School of Medicine and former president of the American Diabetes Association (ADA), who was one of the panelists.
“As many as ten percent of people already show signs of kidney damage when they are diagnosed with diabetes,” he said. “We now have tools to help us start early [treatment]. In order to address a problem, you have to know that it’s there and how severe it is. You’d want to know that there’s a leak in your roof when it’s small, so you can act on it before it gets worse.”
Fellow panelist Jane DeMeis, a patient advocate, peer mentor and ambassador for the National Kidney Foundation and the Know Diabetes by Heart initiative, reinforced this message based on her own experiences with diabetes and CKD.
“I was diagnosed with CKD in 2009 and was already at stage 3b. I did not know anything before that since my doctor and I never had a conversation,” she said. “It wasn’t until I started passing kidney stones that I had the conversation. For those at higher risk, getting a simple kidney test should be automatic at the doctor’s office. For patients who don’t understand CKD, the conversation should happen early. Early detection is the best solution to this problem.”
Starting a conversation about CKD with your healthcare team can help you understand exactly what your test results mean. “Think about getting kidney, blood, and urine tests at least once a year,” said Dr. Joseph Vassalotti, chief medical officer of the National Kidney Foundation and Clinical Professor at Ichan School of Medicine at Mount Sinai. “People with type 2 should get tested every year, and those with type 1 every year after you’ve had diabetes for five years.”
Vassalotti also explained these tests and how to interpret your numbers. He described the two tests used to assess your level of kidney function, the eGFR and UACR.
“The eGFR is a blood test, which you can think of as a percentage of full kidney function. An eGFR of less than 60 [ml/min/1.73m2] is considered to be lower than normal, and the lower it is, the more severe the condition,” he said. “UACR is a urine test, which can be thought of as an assessment of kidney damage, rather than function. In this case, the lower [the number] the better. The UACR is usually listed in mg/g on your lab report. Less than 30 is ideal, 30-300 is moderately elevated, and above 300 is severely elevated. When eGFR is less than 60 or UACR is greater than 30 for at least 3 months, we call that CKD.”
The combination of these two numbers allows your clinician to determine the overall condition of your kidneys and match the severity with the appropriate intervention. Based on these results, you may be referred to a registered dietician, diabetes educator, or nephrologist (kidney specialist). For more on interpreting your kidney numbers check out our article: “Recently Screened for Kidney Disease? Now What?"
While both tests are recommended for all people with diabetes, people often only receive one of the tests, or they’re usually not getting tested early enough. A recent study from the ADA showed that almost 90% of people with type 2 diabetes have received at least one eGFR test, compared to only 53% who have gotten a UACR test.
“Screenings are not done as frequently as they should be,” said panelist Dr. Rachele Berria, the vice president and medical head of US Biopharmaceuticals at AstraZeneca. “When clinicians conduct both tests, they are more likely to act. If you check your blood work and have your eGFR, use the number to initiate the conversation with your healthcare team about whether you need to act. We need proper screening for CKD to translate into diagnosis, which can then lead patients toward the proper treatment. Our biggest opponent is clinical inertia.”
Treatments for CKD
As Berria and the other panelists mentioned, while there is no cure for CKD, treatments today can dramatically slow the progression of CKD, especially if started early. Certain drug classes such as SGLT-2 inhibitors can not only reduce risk for kidney failure, but can also lower your glucose levels and decrease your risk for other complications.
“SGLT-2 inhibitors block your kidneys from reabsorbing glucose and sodium back into your bloodstream,” said Berria. “This can lead to better metabolism, lower blood pressure, and improved cardiovascular (heart) function.”
Farxiga (dapagliflozin), developed by AstraZeneca, is one of the more popular SGLT-2 inhibitors on the market. “In a recent study evaluating the effects of Farxiga (dapagliflozin) in people with CKD, the trial was actually stopped early,” said Berria. “The benefit for patients was so pronounced, that it was considered unethical to continue withholding the drug from people in the placebo arm of the study.” You can read about Farxiga and other SGLT-2 inhibitors such as Jardiance, Steglatro, and Invokana on our drug resource page.
SGLT-2 inhibitors can be a great addition to your diabetes management, but they are not for everyone. For instance, SGLT-2 inhibitors are not approved for people with type 1 diabetes, as they can cause an increased risk for ketoacidosis in this population.
Other medications can also protect your kidneys. “ACE inhibitors and ARBs for blood pressure, SGLT-2 inhibitors for glucose-lowering [effects], and finerenone are all drugs that are indicated to protect your kidneys and reduce your risk for kidney failure,” said Vassalotti.
Medications are not the only, or even the first treatment option, however. Changes to your diet and exercise in particular are often the first thing that your healthcare team will focus on. A healthy diet and physical activity can work together with your medications to help control CKD.
DeMeis, drawing on her own experiences, advocated for weight loss and switching to a plant-based diet. “In 2017, I went back to my nephrologist who said I should be preparing for dialysis within six months,” she said. “I changed my lifestyle, lost about 38 pounds, and felt much better. After struggling again in 2020, I visited a renal dietician and started on a plant-based diet. I have felt great since and have yet to start dialysis.”
“I’ve worked in diabetes for 50 years and never even dreamt of some of the tools we now have to address CKD and other complications,” said Gavin. However, he added,“we should not take lightly that we have training program inadequacies, hospital system regulations, and inadequate exposure to the most current clinical results or latest developments in research, which prevents optimal use of these new tools by many healthcare providers.”
Similar to trends in the prevalence of diabetes, racial and ethnic minorities consistently have higher rates of CKD and dialysis across the United States. “Black, Hispanic, Asian, and Native American populations all have higher rates of type 2 diabetes and higher rates of CKD,” said Vassalotti. “For instance, African Americans represent about 13% of the US population overall, but about 35% of the dialysis population.”
“This is primarily due to social factors such as your access to food, space to get physical exercise, or ability to afford medications,” he said. Social, environmental, and economic factors have a tremendous impact on the health of different populations, directly affecting an individual’s likelihood for facing the negative consequences of diabetes and CKD.
“Social and economic factors include substandard living conditions, poor quality healthcare, health literacy, where you live, possible greater exposure to environmental toxins, access to medications, and even where you are on the transplant list,” said Gavin. “These are all important issues that drive the disparities we’re seeing in kidney outcomes.”
One clear example of how the systems in place can make these disparities worse is how the eGFR is calculated. Race was originally factored into the equation that calculates your eGFR after studies suggested that Black people might have had higher average levels of creatinine in their blood. The racial variable was meant to adjust for this difference.
However, the racialized equation resulted in higher eGFR values, or supposedly better kidney function, for Black individuals. Often this meant Black people experienced longer wait times for receiving a kidney transplant and were less likely to receive one in the first place. An especially problematic fact, considering Black individuals are actually four times more likely than white Americans to have kidney failure.
To address this, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) convened a joint Task Force that recommended that race no longer be considered in the estimated glomerular filtration rate (eGFR). “There will only be one eGFR for all. And we think that this will be good for society, and good for medicine to get away from biologizing race,” said Vassalotti.
To learn more, check out the diaTribe Change article on the new “raceless eGFR.”
While many of these social and economic factors are complex and heavily intertwined, there are resources to improve access to essential treatments by lowering costs.
“For patients with commercial insurance, [AstraZeneca] has savings programs that can reduce the cost of your medication to zero in some cases,” said Berria. “For those who may not have insurance, we have a program called AZ&Me, with a similar program for those on Medicare, to address cost barriers.”
You can find more details about AZ&Me and other cost-saving measures in our article: “How to Get Diabetes Drugs for Free.”
As a final note, each panelist was asked to give a piece of advice to those who may be at risk for developing CKD.
Vassalotti reinforced his advice on medications and getting screened regularly. “If you have diabetes, make sure you’re getting those eGFR and UACR tests at least annually. Know the results,” he said. “If your levels are normal, repeat the tests each year; if not, initiate the conversation with your healthcare team. Lastly, discuss diet, physical activity, and medications with your care team such as ACE inhibitors, ARBs, SGLT-2 inhibitors, and finerenone.”
“First, know your risk factors and if you are susceptible to CKD,” said Berria. “Second, don’t be afraid to take your health into your own hands and approach your provider about your kidney health. With these actions, you can better manage your diabetes, heart disease, and kidney disease.”
DeMeis wished to empower others to become their own best advocates. “Be the captain of your own ship and make your healthcare team work for you,” she said. “Keep track of how you care for yourself and be prepared for your doctor's appointments. If you need support, you can get this through peers. The National Kidney Foundation has an excellent peer mentor program that is great for getting educated about your condition.”
Finally, Gavin concluded with his advice focusing on patient empowerment. “I challenge each of my patients to become an expert in all the aspects of one case of diabetes: their own. Know your risk factors, get tested regularly, and ask your provider to follow up based on the results.”