Expert Tips for Kidney and Heart Health

Leading experts met with about 450 members of the diabetes community for an online conversation about kidney and heart health when living with diabetes. The panelists focused on prevention and also offered insights into advances in treatment.

The discussion was moderated by Dr. Diana Isaacs, director of education and training in diabetes technology at the Cleveland Clinic, and included the following panelists:

• Dr. Robert Gabbay, former chief scientific and medical officer of the American Diabetes Association (ADA)
• Dr. Jennifer Green, professor of medicine in the division of endocrinology at Duke University and faculty member of the Duke Clinical Research Institute
• Dr. Thishi Surendranathan, director of cardio-renal-metabolic medical affairs at Boehringer Ingelheim

Heart and kidney health are interconnected

Kidney disease increases the risk of heart disease, and vice versa, the panelists emphasized, so acting to benefit one will also protect the other.

"They're all connected," said Dr. Robert Gabbay. "The kidneys secrete hormones that control blood pressure, and that can affect the heart. Glucose levels can affect both the heart and the kidneys. So it's important to think of them together."

Dr. Thishi Surendranathan made the point that kidney disease can rapidly progress without a person knowing. And while chronic kidney disease can lead to serious health problems like kidney failure and the need for dialysis, he said, the biggest concern is the elevated cardiovascular risk. 

"In many patients, kidney disease is silent, and there are no symptoms," Surendranathan said. "So it's really important that people with diabetes get screened with the right tests so they can be assessed for their risk."

There are two important ways to test for kidney disease. These tests should be done at least once a year for those with type 2 diabetes and those who have had type 1 for more than five years:

Estimated glomerular filtration (eGFR). "This is a blood test that measures how well your kidneys are filtering waste from your blood," explained Dr. Jennifer Green. "The eGFR is calculated using the creatinine value, but also your age, sex, and body size. It gives a more nuanced or individualized estimate of kidney function than just measuring creatinine."

Urine albumin-to-creatinine ratio (uACR). This test measures albumin, a type of protein found in the blood, and compares it to creatinine, a waste product that comes from the body's muscles and is cleared by the kidneys. There should be none or very little albumin in urine.

A third, more uncommon test is for cystatin C, another protein that's filtered by the kidneys. "Sometimes that's considered a better test in people who have either very low muscle mass or very high muscle mass. For example, a bodybuilder," Green said.

Regular screening is key

Because people with diabetes are at higher risk for heart disease, the ADA recently recommended doctors consider screening patients for their risk of heart failure, even for those who present no symptoms like shortness of breath or swelling in the legs.

Screening is done through an N-terminal pro-BNP test, which measures a hormone (NT-proBNP) that's released by the heart in response to stress, Green said. Because the name is a mouthful, she recommended just remembering the three letters “BNP” and asking at your next doctor's appointment if you need the test. 

"If that level is elevated, then the next step would be to perform an echocardiogram, which is basically an ultrasound of the heart," she said. "And medical therapy could be modified if caught early, to reduce the risk that a person would actually develop symptoms of heart failure."

She said in some of her patients at higher risk of heart disease, she'll also ask for a test called a cardiac calcium score.

"This is an easy, non-invasive test," she said. "Basically, it's a CT scan that measures the amount of calcium buildup in the coronary arteries. I will order this to figure out whether I need to treat someone's cholesterol more aggressively than I might otherwise if I didn't know that they had calcium in their coronary arteries."

If the calcium score is high, Green said she would then consider referring the patient to a cardiologist. 

Medication strategies

The panelists stressed the need for individualized treatment plans based on a person's needs. They also discussed the need to find effective treatments that patients can afford.

For those with high blood pressure, the first line of defense is typically the class of drugs called ACE inhibitors. They prevent the production of a hormone called angiotensin II, which narrows blood vessels. Because ACE inhibitors cause blood vessels to relax, blood pressure is lowered.  

"Almost everybody who's at risk should be on these drugs first and foremost," Surendranathan said. 

ACE inhibitors and other drugs to lower blood pressure are frequently available as generics, making them fairly inexpensive.

Turning to newer medications, Surendranathan described the effects of SLGT-2 inhibitors, which were developed for better blood sugar control. As the kidneys filter blood, SLGT-2 drugs block glucose from being reabsorbed into the bloodstream. Instead, the glucose exits via urine, lowering blood sugar levels. 

"The SLGT-2 medicines reduce injury to the kidneys over time and slow the progression of kidney disease. They also have a beneficial impact on the heart."

The same is true for GLP-1 receptor agonists. The two drugs can be used together to complement their effectiveness, Surendranath said, while promoting weight loss, which is also beneficial to the heart and kidneys.

Gabbay also referred to a more recently developed medicine, finerenone, which can lower glucose levels and protect kidney and cardiovascular health. 

Access and other barriers

The panelists discussed challenges to heart and kidney health, including access to medicine and care. People with diabetes often find that staying on top of preventative care is a challenge, Gabbay noted. 

"Life is hectic, and people are busy," he said. "Going to see your healthcare professional regularly is a great reminder, because they'll sit down and say, 'OK, let's think about what we can do together.'"

Cost is another barrier, the panelists said, and some ongoing care, such as GLP-1 and SGLT-2 drugs, can be expensive. 

"There are programs available for people that are unable to afford medications," Gabbay said. "Your healthcare professional can point the way to that. And a number of organizations, like the ADA, are advocating to ensure that people have access to treatment."

Future generics may reduce the costs of these drugs, the panelists said. For example, the makers of the GLP-1 weight-loss drugs Wegovy and Zepbound have reduced the price to under $500 a month when using their direct-to-consumer online pharmacies.

"I wish it were more straightforward, but the fact is that most people with diabetes who are considered at high risk for these complications can access these newer drugs," Green said. It can be difficult for your doctor or pharmacist to figure out which one, but I would encourage healthcare providers and you to ask to keep trying until you figure out which one. It's not an easy road, and it requires some extra work, but keep trying. It is worth it."

The bottom line

Kidney and heart disease are intertwined, and their prevention is best addressed together, a panel of experts emphasized. 

Early detection and intervention are key. People with diabetes should get yearly albumin-to-creatinine (urine) and eGFR (blood) tests and make sure those results are shared between primary care doctors and any specialists.

Lifestyle changes, such as quitting smoking, reducing salt intake, and starting regular exercise can also greatly reduce the risks of heart and kidney disease. 

In addition, medications including SGLT-2 inhibitors, GLP-1 receptor agonists, and ACE inhibitors, can be very beneficial in preventing heart and kidney disease as well as slowing its progression.

Learn more about heart and kidney health with diabetes here:

• Connecting the Pieces for Better Cardiovascular, Kidney, and Metabolic Health
• Can We Make Conversations About Diabetes Complications Less Scary?
• New Hope for Treating Chronic Kidney Disease in Type 1 Diabetes
• Heart Failure – The Overlooked Diabetes Complication, Part 2: Prevention and Management
• Diabetes Remission Reduces Risk of Kidney and Heart Disease
• The DASH Diet: A Heart-Healthy Eating Plan