by Ed Bryant
I am a long-term diabetic who experienced renal failure. On August 9, 1983,
I had a kidney transplant. To date, 21 years later, I feel great, and the new
organ is functioning perfectly.
Knowing that nephropathy, kidney failure, is a frequent complication of diabetes,
what can YOU do to prevent, minimize, or slow it? There is a tight statistical
link between quality of diabetes control -- and ramifications such as heart
and blood vessel disease, diabetic eye disease, and diabetogenic kidney failure.
We know the tighter your control, the less chance you will experience these
complications. Good self-management is the BEST way to cut the risk.
There are things you can do. First, don't smoke. Nicotine, the narcotic active
ingredient in tobacco, is a vasoconstrictor, raising blood pressure, stiffening
capillaries, and making it harder for the kidneys to filter wastes.
Urinary tract infections need prompt treatment, to limit the damage they can
do to already strained kidneys. Tell your doctor promptly if you think you have
such an infection.
Excessive obesity raises blood pressure and increases insulin resistance. Keeping
your weight down helps in general, and the resultant blood pressure drop is
good for your kidneys.
You need to control your cholesterol, as too much of this fatty substance in
your blood overworks your kidneys. Proper diet, exercise, and appropriate medications
can lower your cholesterol levels. Consult a Registered Dietitian (RD) for advice;
kidney failure imposes unique constraints.
High levels of stress can be damaging. It drives up blood pressure, can harm
the kidneys by raising fluid pressure, further straining already weakened filter
networks. Stress reduction is part of a healthy lifestyle. Ask your health care
team for advice here.
Other than "keep your diabetes under the best possible control, and live
a healthy lifestyle," I can offer little advice about prevention.
Once kidney disease is diagnosed, however, a great deal can be done to retard
its progression. Current statistics suggest perhaps four out of every ten diabetics
may experience measurable kidney disease, though many of these individuals should
be able to avoid progressing to outright kidney failure, End Stage Renal Disease
(ESRD).
Testing Your Kidney
How is the severity of kidney disease measured? Several tests measure creatinine,
a waste product from muscle mass. Although everyone's body produces creatinine,
people whose kidneys are failing cannot properly excrete it. One test measures
the amount of creatinine in the blood, and the other is "creatinine clearance,"
a 24-hour urine test. Normal "blood creatinine," for someone with
healthy kidneys, is about 0.7 to 1.3. Government guidelines (April 1995) recommend
dialysis when the blood creatinine rises to 6 or above (the number rises as
you get worse). However, some diabetics will experience kidney failure before
that point. There is much variation between individuals who have ESRD, and the
actual range for "kidney failure" runs from 3 through 8-but at or
above 6, Medicare will pay for dialysis.
"Creatinine clearance" is considered a more reliable test. In this
24-hour urine test, the numbers produced approximately indicate the percent
of normal kidney function remaining to the individual (the number goes own as
you get worse). The 1995 government guidelines (which relate to Medicare part
B eligibility) state they will fund dialysis when this test produces a reading
of 15 or less.
Two other tests measure protein spillage into the urine. These are the microalbumin
test and the test for proteinurea. The protein albumin is not normally excreted
into the urine, and its presence in the urine, in small amounts (microalbuminuria)
or larger concentrations (proteinurea) can indicate kidney disease. While not
considered absolute diagnostic evidence, a positive finding in either should
be immediately followed by further testing, as these tests are very sensitive,
and the microalbumin test can detect kidney disease long before the other tests-allowing
earlier medical intervention.
Options
Individuals experiencing impaired kidney function, but whose test results indicate
they do not yet need dialysis or transplantation, might benefit from regular
use of ACE (Angiotensin Converting Enzyme) Inhibitors, commonly used to control
hypertension, high blood pressure. Now widely accepted, these ACE Inhibitors
have been shown to significantly reduce further kidney degeneration. Note: A
diabetic experiencing kidney failure, but whose blood pressure is not elevated,
can still use ACE Inhibitors for keeping fluid pressure down in the kidneys.
This therapy has been shown to significantly reduce strain on eyes and cardiovascular
system, as well. Talk to your nephrologist (kidney specialist) about the ACE
Inhibitors.
End Stage Renal Disease
The damaged kidney may worsen to the point where it can no longer carry out
its blood-purifying function. Then dialysis or transplantation are necessary
in order to preserve life. This is ESRD, end stage renal disease. What are your
options then?
There are three: In hemodialysis, the patient's circulatory system is temporarily
linked with a machine that performs the blood-cleansing functions of the human
kidney. In peritoneal dialysis (CAPD or CCPD) a tube is inserted into the patient's
peritoneal cavity, allowing urine and unneeded fluids to periodically drain
from the body. The third option is kidney transplantation, in which a donated
kidney is surgically implanted into the patient's body.
National Institutes of Health statistics show that 42.9 percent of all individuals
facing dialysis are there because of diabetes, and about 40 percent of those
commencing dialysis or seeking a transplant at this time are diabetic. Some
remain on dialysis long-term; others make use of the process while awaiting
a kidney transplant.
Dialysis
Dialysis is not an "artificial kidney." A person undergoing hemodialysis
must be hooked up to a machine three times a week, three to four hours per session.
Like the kidney, a hemodialysis machine is a filter. Where it uses tubes and
chemicals, the kidney uses millions of microscopic blood vessels, fine enough
to pass urine while retaining suspended proteins. Long-term high blood glucose
can significantly damage the kidney's filters, leading to scarring, blockage,
and diminished renal function. Diabetes is the leading cause of kidney disease
(the second is hypertension). Long-term diabetics often have cardiovascular
and blood pressure problems as well, and the added strain of hemodialysis, with
its rise in blood pressure straining eyes and heart function, can be too much
for some. The diabetic dialysis patient spends, on the average, 33 percent more
time in the hospital than does the non-diabetic dialysis patient, according
to 1999 USRDS figures.
Some patients choose CAPD (continuous ambulatory peritoneal dialysis) or its
variant, CCPD (continuous cycling peritoneal dialysis), both of which can be
carried out at home, without an assistant. Though the risk of infections is
heightened (as it is with any permanent catheterization), these two processes
have their advantages.
Transplantation
Kidney transplantation is a logical alternative for many. A transplant frees
the patient from the many hours spent on hemodialysis procedures each week,
or from the periodic "exchanges" and open catheter of CAPD, allowing
a nearly normal lifestyle. It can bring real improvement in quality of life
and overall longevity.
An article, published November 1999 in the New England Journal of Medicine,
shows the longevity gains have been major. The average graft survival (how
long the kidney remained functional, not the patient) was, from a living donor,
17 years, in 1988. Per 1996 statistics, it is now 36 years. The typical cadaver
kidney transplanted in 1988 lasted 11 years, but in 1996, the life expectancy
of the organ was nearly 19 years. The study, led by Dr. Sundaram Hariharan,
at the Medical College of Wisconsin, funded by the National Institutes of Health,
concludes the improvement is largely due to the development of better anti-rejection
medications.
"Fifty percent of all kidney transplantations taking place today are into
diabetics," states Giacomo Basadonna, MD, PhD, a transplant surgeon at
Yale University School of Medicine, in New Haven, Connecticut. He reports that
success rates are identical with kidney transplants performed on non-diabetic
ESRD patients. "Today," he advises, "average kidney survival,
from a living donor, is greater than 15 years."
"Will you survive longer once you get a transplant?" asks Marianna
Markel, MD, Director of Transplant Nephrology at SUNY Health Science Center,
in Brooklyn, New York. "If you're a diabetic, it looks like the answer
may be yes, perhaps because certain substances which build up in the blood of
diabetics (advanced glycosylation end-products) are not removed well by dialysis,
and may contribute to a shortened lifespan for diabetic patients on dialysis."
I and others knowledgeable in kidney transplantation advise you to pick the
best transplant center possible. Once you have read their statistics, ask your
prospective center plenty of questions. If they don't answer to your satisfaction,
you should consider going to another center.
Facts and Statistics
What is the success rate for kidney-transplant surgery? According to the "United
States Renal Data System 1999 Annual Data Report," published by the National
Institutes of Health, about 75 percent for a cadaver-donated kidney, better
than 90 percent with a kidney donated by a living relative, with an overall
success rate of better than 85 percent, better than 90 percent in some centers.
UNOS data indicate the averages (based on graft survival, healthy kidney, five
years after transplant) are improving. The National Institutes of Health reports
that current "graft survival" (donated kidneys successfully functioning
in the transplant recipient) rates are approximately the same now, whether the
recipient has diabetes or not.
What percentage of type 1 diabetics will face ESRD? Current statistics suggest
between 20 and 25 percent, with many factors (genetic, ethnic, lifestyle) taken
into account.
Must the ESRD patient be on dialysis before being considered eligible for a
transplant? NO! Although some behind-the-times nephrologists still believe so,
Fairview-University Medical Center's Transplant Center, which pioneered diabetic
kidney and pancreas transplantation, recommends once your physician has determined
kidney failure is on the way, further delay could be harmful. The more time
spent subjecting your body to the toxic excesses of kidney failure and the strains
of dialysis, the greater the risk of serious complications like retinopathy
and cardiovascular (heart) degeneration.
Your nephrologist should be able to tell you more about your options. For information
about kidney transplantation, contact a reputable kidney transplant center (there
are approximately 250 in the U.S. today), or the United Network for Organ Sharing,
1100 Boulders Park, Suite 500, Richmond, VA 23225; telephone: 1-800-243-6667;
website: (www.unos.org). All UNOS information is available on the World Wide
Web, but they will also send you pertinent information, by mail, about transplant
centers in your area or nationwide. Contact them at the above address, and ask
them for the "kidney transplant package." They also offer the brochure
"What Every Patient Needs to Know," and an organ-donor card for you
to carry.
For information or assistance with interpreting transplant center data, contact:
Health Resources and Services Administration, Bureau of Health Resources Development,
Division of Transplantation, OSP, Park Lawn Bldg., 5600 Fishers Lane, Room 7C-22,
Rockville, MD 20857; telephone: (301) 443-7577; website: (www.hrsa.gov/osp/dot).
This agency also maintains the website: www,organdonor.gov, which offers many
useful links and much pertinent information.
Renal failure is not a kiss of death. There are options, and at least one of
them will be right for you. Keep your diabetes under good control, and your
blood pressure down, to cut the risks-but if it happens (like it did to me),
remember that with proper care you stand every chance of living just as long
as you would have with healthy kidneys.