How To Keep Your Kidneys Healthy When You Have Diabetes
Having diabetes puts you at risk for problems with your kidneys. Learn about the steps you can take, as recommended in the latest ADA Standards of Care, to maintain the health of your kidneys and prevent damage.
Your kidneys play an integral role in keeping you healthy. Their main job is to filter waste products out of the body along with extra fluids in the form of urine. The kidneys also play a role in keeping blood pressure normal and making several important hormones the body needs for overall healthy functioning.
Unfortunately, it’s estimated that 20-40% of people with diabetes develop what’s known as chronic kidney disease (CKD) due, in part, to less than optimal glucose and blood pressure management. Keeping these measures within target ranges, eating nutritious food, and taking medications that help prevent or delay CKD are all actions that can go a long way in keeping your kidneys healthy.
Based on the latest guidance from the American Diabetes Association (ADA)’s Standards of Care, here are steps you and your healthcare team can take for the prevention and management of diabetes-related kidney disease.
How does kidney damage due to diabetes happen?
High glucose and blood pressure levels over many years can slowly damage the small blood vessels in the kidneys. These damaged blood vessels don’t clear the body’s waste products as well, which in turn can cause damage to the kidneys.
Early signs of kidney damage can go unnoticed (chronic kidney disease is sometimes referred to as a “silent complication”), which is why screening is so important for people with diabetes. Other risk factors for CKD include:
- Smoking
- A high sodium diet
- Not enough physical activity
- Excess weight or obesity
- Heart disease
- Family history of kidney failure or kidney disease
In addition, having CKD can increase a person’s risk for heart and blood vessel diseases.
Stages of chronic kidney disease
Though the goal is ideally to prevent CKD, it is valuable to know about the six stages of kidney disease as illustrated below.
People with diabetes who are diagnosed with CKD typically – but not always – have had diabetes for many years. As mentioned, it’s important to remember that people diagnosed with CKD generally do not know it until their kidneys are already damaged. This is one reason why it’s so important to get regular checks and tests to screen for kidney disease.
People who have continuously increasing urinary albumin levels or continuously decreasing eGFR results (markers of kidney disease) should be referred to a nephrologist, or kidney disease specialist. Consulting with a nephrologist at this point has been found to reduce cost, improve quality of care, and delay dialysis.
People who develop stage 5 CKD or kidney failure generally need to start a form of dialysis. There are two types, hemodialysis and peritoneal dialysis. There have been many advances in how and where dialysis can be done. Some people with CKD might be a candidate for a kidney transplant, but still may need dialysis while waiting for a donor kidney.
If you are told you have indications of kidney disease, be sure to take the next steps promptly. Kidney problems will likely progress or worsen over time without treatment.
How to prevent or delay diabetes-related kidney problems
As is true for the prevention or delay of most diabetes-related problems, there are actions to take daily, like keeping your blood sugar and blood pressure well managed. There are also screenings and appointments you should do annually (or more frequently, depending on your circumstances) to detect any issues. Here are some steps you can take to help keep your kidneys healthy with diabetes.
Aim to keep glucose in a desired target range
Blood sugar management over time can help reduce the risk or slow the progression of CKD. Work with your healthcare team to come up with glucose targets that are best for you.
If you have type 2 diabetes, talk to your care providers about taking an SGLT-2 inhibitor, such as Farxiga (dapaglifozin), Jardiance (empagliflozin), Invokana (canagliflozin), or Steglatro (ertugliflozin). SGLT-2 inhibitors help prevent the progression of CKD by reducing the amount of glucose that is reabsorbed by the kidneys and increasing the amount of glucose put out in the urine (though these medications are being used off-label by some people with type 1 diabetes, they are not yet approved by the FDA for this use).
Regarding kidney function specifically, research shows that these medications can reduce weight, blood pressure, albuminuria (a symptom of kidney disease), and estimated glomerular filtration rate (eGFR) (a marker of kidney function). Research shows that SGLT-2 inhibitors like Jardiance can also protect against heart failure.
If you have type 2 diabetes and are at especially high risk for CKD progression or heart disease, talk to your healthcare provider about a relatively new FDA-approved medication called Kerendia (finerenone), which can be used alongside SGLT-2 inhibitors. It has been shown to slow the progression of CKD and have heart-health benefits such as reduced risk for heart failure.
Aim to keep your blood pressure in the recommended range
If you have high blood pressure, work with a healthcare provider to understand what blood pressure target is best for you. Sometimes blood pressure can be managed with lifestyle changes like exercise and diet – effective eating plans for blood pressure include the DASH diet (Dietary Approaches to Stop Hypertension) – but medication may be needed.
Make sure to get your blood pressure taken at every routine clinical visit (most providers will take your blood pressure, but in case they don’t, insist on it being checked). If you have high blood pressure, it’s also recommended that you monitor your blood pressure at home.
As is the case for managing blood sugar, managing blood pressure depends on your numbers and any other risk factors. If your blood pressure is greater than 120/80 mmHg (but lower than 130/80 mmHg), certain lifestyle changes may help. One example is reducing the amount of sodium you consume to less than 2,300 mg/day. Some people (but not all) may need to reduce the amount of potassium they consume.
If your blood pressure is at or greater than 130/80 mmHg, in addition to lifestyle changes you will likely be prescribed a blood pressure medication to help reach your target goal. There are several classes of blood pressure lowering medications that can reduce adverse heart and blood vessel problems and prevent or reduce the progression of kidney disease. Two types that are best for people with diabetes to start with are ACE inhibitors and ARBs (angiotensin receptor blockers).
Note that the use of an ACE inhibitor or ARB is not recommended for people with diabetes who have normal blood pressure and normal kidney function measures, including urinary albumin-to-creatinine ratio and normal estimated glomerular filtration rate (more about these measures below).
To adequately manage blood pressure to achieve your target goal, you may also need to add another type of blood pressure medication, such as a calcium channel blocker or diuretic. If you take a diuretic, your provider should measure and monitor your potassium levels.
Monitor how much protein you eat
To prevent or slow the onset of CKD – and live a healthier lifestyle in general – try, as much as possible, to practice essential healthy lifestyle and self-care behaviors. This includes regularly monitoring your protein intake (the kidneys help remove protein waste from the blood and expel it through the urine).
People with stage 3 kidney disease who do not yet need dialysis should eat a maximum of 0.32 grams/pound of protein per day but not less than this amount. For example, this amount for a woman of average height weighing 140 pounds is around 51 grams of protein per day. For a man of average height weighing 180 pounds, this amount is around 58 grams of protein per day.
Note that this is not a protein restriction: It is the amount of protein recommended for all adults. In comparison with eating higher amounts of protein, this level has been shown to slow progression of CKD. People on dialysis may need more protein to reduce malnutrition.
Get annual tests to check kidney function
If you have type 2 diabetes or have had type 1 diabetes for five years or more, there are two tests to check your kidney function. Diabetes-related kidney disease can typically develop after having type 1 diabetes for 10 years but may already exist in people with type 2 diabetes when they are diagnosed. If you have been diagnosed with diabetes-related kidney disease, you may need to have these tests done more often (one to four times per year):
- Urine albumin-to-creatinine ratio (uACR): This test assesses the amount of protein (albumin) that is spilling from your kidneys into your urine. Normal to mildly increased uACR results are less than 30 milligrams/gram, moderately increased is 30-299 milligrams/gram, and severely increased is 300 milligrams/gram or higher.
- Estimated glomerular filtration rate (eGFR): This test measures the rate at which your kidneys are filtering waste products. eGFR is calculated from your age, serum creatinine level, and gender. Creatinine is a blood test that measures the amount of protein that your body is breaking down. An eGFR result of at least 90 indicates normal kidney function. See the chart above for additional details about how eGFR determines the severity of kidney damage.
Perspectives from a person with diabetes and kidney disease
To gain insights into the practical and emotional aspects of diabetes and CKD, we talked to Anne Dalin, 69, who has had type 2 diabetes for about 21 years. Dalin is a meetups co-leader for DiabetesSisters in New Jersey. She is also a tireless volunteer and advocate for the National Kidney Foundation.
Dalin had a heart attack in 2001, at age 48. Initially, damage to her kidneys was thought to be caused by the dye used to insert stents in the blood vessels around her heart. Soon after her kidney damage was detected, she was diagnosed with type 2 diabetes. Dalin said that it's likely she had diabetes for many years before being diagnosed, and that years of high glucose and blood pressure levels caused kidney damage and eventual progression to stage four CKD.
Dalin thought she would need to be on dialysis until she could obtain a kidney transplant. But as luck would have it, her son was a kidney donor match, and the transplant was done early in 2019.
“Don’t put off the regular checkups and tests to check the health of your kidneys,” said Dalin. “Don’t wait for symptoms, because it’s extremely uncommon to have them until you have significant kidney disease.”
Today, Dalin works hard to keep her diabetes, heart and blood vessels, and transplanted kidney, healthy. She carefully watches what she eats and walks regularly. She will always be on medications to suppress her immune system to prevent her transplanted kidney from failing.
“Managing my health is second nature to me now,” she said. “Even if I’m busy, I set an alarm on my phone to remind me to take my medications.”
What works for Dalin may not work for you, which is why it’s important to work closely with a healthcare team to determine what steps for prevention or management of kidney disease are best for you.
About this series
Each year, the American Diabetes Association updates its Standards of Medical Care in Diabetes based on current science. We’ve translated key points of the up-to-date Standards into plain English so you know how to stay healthy and minimize diabetes complications.
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