Introduction:

Diabetes mellitus is chronic condition in which the islet of Langerhans cells of the pancreas either fails to produce the insulin hormone (Type 1 or juvenile onset diabetes) or produces very little amount of insulin hormone (Type II or adult-onset diabetes). Insulin is the major pancreatic hormone which regulates the blood sugar level. As a result of diabetes, the blood sugar level elavates significantly. Diabetes is a major issue of public health concern and is also a leading cause of chronic kidney disease worldwide. Statistics reveal that 1 out of 3 diabetic adults worldwide end up with chronic disease. Around 30% of patients with type I diabetes and around 40% of patients with type II diabetes or adult-onset diabetes eventually suffer from diabetic kidney disease and kidney failure. Hence diabetic chronic disease is extremely widespread. Diabetes kidney disease can also be referred diabetic nephropathy. The nephrons are damaged which are the structural and functional units of the kidney. Hence the condition is termed as “Diabetic nephropathy”. High blood sugar can cause damage to the blood vessels present in the kidneys. Because of this, the kidneys wont any longer be able to carry out its normal activity of filtering nitrogenous toxic wastes out of the body. So, the toxic products would end up in the blood instead. Diabetes persisting over a longer period can lead to diabetic kidney disease, kidney damage and eventually lead to death. When a person’s blood sugar or blood pressure is high, the chances of developing diabetic kidney disease are considerably high. Poorly controlled diabetes causing damage to the kidney’s vessels that function to filter toxic wastes out of the body. This leads to hypertension by creating unnecessary pressure on and injuring the delicate excretory system which ultimately culminates into kidney damage. 

Causes of Diabetic kidney disease: 

With both the quality and amount of the food, excessive calorie consumption is one of the key drivers driving obesity that leads to type 2 diabetes. The quality of carbohydrates and fats play a crucial role in the development of diabetes, with a higher glycemic load (GL) in the diet and the presence of trans fat increasing the risk of the illness. Such conditions persisting over a long period of time can cause kidney diseases.

The increased use of sugary beverages by people all over the world leads to obesity and diabetes since it has a stronger impact on body weight. Obesity and uncontrolled BMR can lead to diabetes, which left untreated may result in kidney disease. 

Rapid social and economic development in developing countries leads to changes in people’s dietary structures and lifestyles, promoting overnutrition and energy imbalance in the body. As a result, the traditional dietary pattern has been lost, and individuals have chosen urban and industrialized food settings. These dietary alterations contribute to type 2 diabetes as a result of decreased physical activity, central obesity, and nutrition transition. This also due to the lower cost of sugar and edible oil as a result of global trade liberalization. Sedentary lifestyle, adherence to poor dietary regimen contributes to diabetes that culminates in kidney disease. 

People are more likely to smoke cigarettes as a result of the shift in lifestyle, which is a major cause of type 2 diabetes, with a 45 percent increased chance of developing diabetes. Another obstacle to overcome is noncompliance with anti-diabetic therapy. Diabetic patients frequently neglect to take the prescriptions and drugs given by their doctor, or to properly follow a new dietary regimen, resulting in hyperglycemia exacerbations and diabetic complications. Such diabetic complications end up in kidney diseases. 

Millions of microscopic blood vessel clusters (glomeruli) filter waste from the blood in the kidneys. Diabetic nephropathy, impaired kidney function, or kidney failure can all result from severe damage to these blood arteries of the kidney. Diabetic nephropathy is hence caused by diabetes. Diabetic nephropathy is common type 1 and type 2 diabetic consequence.

                             Figure 1: Pictorial representation of diabetic nephropathy 

Poorly controlled diabetes can damage blood vessel clusters in the kidneys, which filter waste from the blood, over time. This can elavate the blood pressure.

High blood pressure can worsen kidney disease by raising pressure in kidneys’ sensitive filtering system.

Fatalities of diabetic kidney disease:

Diabetes causes damage to the body’s tiny blood vessels of the glomerulus (which are tuft in capillaries present in the nephron of the kidney). When the blood arteries in the kidneys are damaged, the kidneys are unable to adequately clear the blood. The body will retain more water and salt than it should, leading to weight gain and swelling in the ankles. Protein may be present in the urine. In addition to this, waste elements will accumulate in the blood. This leads to a decreased GFR (Glomerular filtration rate).

Diabetes can also harm the nerves in the body. It may be difficult empty the bladder as a result of this. The pressure created by a full bladder might cause the kidneys to get injured. In addition, if urine stays in the bladder for a long time, germs can proliferate quickly in urine with a high sugar level, causing a microbial infection. End-stage renal failure, often known as kidney failure, can follow from diabetic kidney disease. This happens when one’s kidneys are no longer able to keep them alive and necessitates dialysis or renal transplantation. This occurs when the kidneys only operate normally to a certain extent, at around 10% to 15% of their normal capacity.

Reversibility of diabetic kidney disease:

Kidney impairment can occur 10 to 15 years after the onset of diabetes. The kidneys grow less effective at purifying the blood as the damage progresses. The kidneys can stop working if the damage is severe enough. Kidney damage is irreversible.

The proper functioning of the kidneys is crucial to one’s overall health. The kidneys can’t filter blood as well as they should if one has CKD, While it is impossible to repair kidney damage, there are things one may take to slow it down. Kidney impairment can occur 10 to 15 years after the onset of diabetes. The kidneys grow less effective at purifying the blood as the damage progresses. The kidneys can stop working if the damage is severe enough. Kidney damage is irreversible.

The proper functioning of your kidneys is crucial to a person’s overall health. The kidneys can’t filter blood as well as they should if one has CKD, . While it is impossible to repair kidney damage, there are things you may take to slow it down.

While drinking more water can improve kidney function, dialysis can increase longevity of an individual and improve their quality of life, but still, it is a daunting and lifelong process that compromises the health and overall physical and mental wellbeing of an individual. Renal transplantation can significantly improve the health outcome of a patient but it is often a very tedious process with finding an ABO compatible donor, and HLA matched donor. 

Signs and symptoms of diabetic kidney disease:

Deterioration of blood pressure regulation: 

Hypertension (high blood pressure) is a primary cause of kidney disease and failure (end-stage renal disease). Hypertension can damage the blood arteries and filters of the kidney, making it difficult to remove waste from the body.

Kidney disease reduces the ability of the kidneys to assist regulate blood pressure. Blood pressure rises as a result. High blood pressure makes it more likely that your renal disease will worsen and that you will have cardiac problems if you have CKD.

The kidneys are unable to filter the blood effectively or obtain enough oxygen to function if they do not have access to enough blood. The kidneys gradually shut down as a result of these difficulties caused by low blood pressure.

Urine with protein or proteinuria- 

Proteinuria is a condition in which there is an excess of protein in the urine. This symptom could indicate renal impairment. Proteins should stay in the bloodstream because they help create muscle and bone, regulate blood volume, fight infection, and repair tissue. Proteinuria can also be caused by the following dangerous conditions: Systemic Lupus erythematosus is an example of an immune illness. Kidney inflammation (glomerulonephritis) is a condition in which your body loses an excessive amount of protein when one urinates. This puts you at higher risk of developing chronic kidney disease.

Foot, ankle, hand, or eye swelling: 

The kidneys filter wastes from bloodstream and excrete excess water through urine. This fluid can linger in the system instead of being expelled if the kidneys aren’t doing their job. Swelling in the hands, feet, and ankles could indicate kidney or heart failure and should not be ignored. Reduced renal function can cause salt retention, which causes edema in the feet and ankles. Heart illness, liver ailments and chronic leg vein issues can lead to the swelling of lower limbs.

Confusion or inability to concentrate: Sugar is, in reality, the brain’s primary source of energy. As a result, if your blood sugar is out of whack as a result of diabetes, you can experience cognitive fog. Reduced concentration, for example, is a symptom of brain fog.

Delirium can occur when diabetes is not well controlled. This severe state of perplexity and behavioral alteration is difficult to treat and is linked to a higher risk of long-term cognitive impairment and possibly mortality. 

                        Figure 1: Signs and symptoms of diabetic kidney disease 

                                             (Source: Created by self)

Breathing problems: 

Acute renal failure can cause fluid to build up in the lungs, causing shortness of breath. Pain in the chest. One may suffer chest pain if the lining that surrounds their heart (pericardium) gets irritated.

Pulmonary edema, hemorrhagic pleuritis, bronchial calcification, and a tuberculosis propensity are all respiratory consequences of chronic renal failure.

Appetite loss and fatigue: 

Compounds build up in the blood in the early to middle stages of renal disease, suppressing hunger and affecting one’s perception of taste. Nitrogenous wastes and accumulation of fluids that one used to enjoy may begin to taste metallic. Appetite loss can be caused by depression, anxiety, drug abuse, and other fatal consequences.

Vomiting and nausea: 

Nausea and vomiting are prevalent in kidney patients and can be caused by a variety of factors. The accumulation of uremic toxins, medicines, gastroparesis, ulcers, gastroesophageal reflux disease, gallbladder disease, and many other factors are among the reasons.

Itching that doesn’t go away: 

Nausea and vomiting are prevalent in kidney patients and can be caused by a variety of factors. The accumulation of uremic toxins, medicines, gastroparesis, ulcers, gastroesophageal reflux disease, gallbladder disease, and many other factors are among the reasons.

Risk factors and complications associated with diabetic kidney disease:

Factors that can raise your risk of diabetic nephropathy if you have diabetes include: High blood sugar that is uncontrolled (hyperglycemia) High blood pressure that is uncontrolled (hypertension) Being a cigarette smoker

High glucose levels, obesity, dyslipidemia, raised blood pressure, oxidative stress, and other risk factors all contribute to the development and progression of diabetic nephropathy. The majority of these risk factors can be changed.

Diabetes, Blood pressure that is too high, Heart (cardiovascular) illness is a condition that affects the heart and circulatory system, Smoking, Obesity.

Kidney illness runs in the family.

Structure of the kidneys is abnormal.

Weight. The body cells become more insulin resistant as one gains more fatty tissue.

Inactivity. Prolonged periods of inactivity contribute to diabetes and increase risk of CKD. 

This particularly pertinent to the current Covid 19 scenario, sedentary lifestyle is the norm in the Covid 19 pandemic period, which has raised the propensity of diabetes as well chances of diabetes associated kidney diseases and subsequent kidney failure. 

History of the family is also a risk factor of diabetic kidney disease. 

Genetic predisposition inclusive of ethnicity or race, Age, are also important risk factors of diabetic nephropathy. Diabetes during pregnancy, polycystic ovarian syndrome (PCOS) is a kind of polycystic ovary syndrome (PCOS) are common causes of diabetic nephropathy. Blood pressure that is too high can also be cited as a major risk factor for diabetic kidney disease. 

Prevention of diabetes kidney disease: 

Maintaining regular diabetes management appointments with healthcare professionals would help to lower the chance of developing diabetic nephropathy. 

Maintaining annual appointments — or more frequent meetings with the health care provider to assess the diabetes management schedule. To test for diabetic nephropathy and other complications is an absolute prerequisite.

Taking care of diabetes is essential. Diabetic nephropathy can be avoided or procrastinated with proper diabetes management.

Taking care of high blood pressure and other medical issues would be necessitated. 

Regular Consultation with doctors is required if one has high blood pressure or other factors that raise the risk of renal disease.

 Nonprescription pain medications including aspirin and nonsteroidal anti-inflammatory drugs like naproxen (Aleve) and ibuprofen have instructions on the container (Advil, Motrin IB, others)

Maintaining a healthy body mass index (BMI) would be required. If one is at a healthy weight, try to keep it there by exercising most days of the week. If one needs to reduce weight, discuss weight-loss measures with the concerned physician, such as increasing daily physical activity and eating fewer calories.

Quitting smoke would be required. Cigarette smoking can harm the kidneys and exacerbate any existing damage. Speaking with the doctor about stopping smoking tactics if one is a smoker. This can be made easier with the help of support groups, counseling, appropriate rehabilitation programs, and some medications.

Treatment strategies for diabetic kidney disease:

Dialysis, often known as artificial kidney, is the process of filtering urine outside of the kidney. Hemodialysis is the most often used type of dialysis. Peritoneal dialysis is the alternative option.

Hemodialysis is a type of kidney replacement therapy in which the blood is filtered outside of the body. The dialyzer, a dialysis filter that acts as an artificial kidney, is at the heart of hemodialysis. During treatment, it purifies the patient’s blood. A dialysis machine pumps the blood, gives anticoagulants, and checks circulation while the blood cleansing procedure is taking place inside the dialyzer. Peritoneal dialysis: This type of dialysis filters the blood inside the body. A catheter is used to deliver dialysis fluid to the abdominal cavity. 

Benefits of Dialysis: If dialysis is done on a regular basis, the following are the advantages (3 times a week). A higher standard of living, Chances of survival are better, Hospital visits are less frequent. There are less complications.

Renal transplantation is the procedure of transferring a kidney from a donor to a recipient (having an impaired kidney). It’s possible that the donor is a cadaver or a living person. Only individuals with end-stage CKD should undergo this procedure. ABO compatibility and HLA typing are required for finding an ideal match. Finding an excellent match for a renal failure recipient, on the other hand, can be a time-consuming process.

Therapeutic interventions for diabetic kidney disease: 

Diabetic nephropathy treatment strategy may include drugs to manage the following symptoms in the early stages: Control of blood pressure. High blood pressure is treated with angiotensin-converting enzyme (ACE) inhibitors and angiotensin 2 receptor blockers (ARBs). Metformin, an oral diabetes medication, is generally safe for diabetics with chronic kidney disease (CKD). Metformin is used extensively for treating diabetic patients having high blood sugar level and a primary antidiabetic regimen. Insulin produced by the pancreas is unable to transport sugar into the body’s cells where it can function properly in this type of diabetes.

To control high blood sugar, metformin is combined with a healthy diet and exercise routine, as well as other drugs. It is prescribed for type 2 diabetes patients.. High blood sugar control can help prevent kidney disease, blindness, nerve problems, limb loss of limb amputation, and sexual function issues, and reduce the chances of cancer, cardio vascular disease, stroke, dementia etc. associated with diabetic kidney disease. 

In patients with CKD, glipizide is the preferred SU. Glipalamide and glyburide are both processed by the liver and excreted in the bile and urine in identical amounts. Patients with renal failure may experience severe hypoglycemic episodes, and the medications are contraindicated from stage 3 of CKD (eGFR 60 mL/min). 

Acetazolamide is a carbonic anhydrase inhibitor. It inhibits the renal enzyme Carbonic Anhydrase (CA). This enzyme normally functions to reabsorb the bicarbonate in the kidneys. So acetazolamide depletes the body of bicarbonates, expedites its excretion, and causes temporary metabolic acidosis. For understanding the mechanism of Diamox, studying the physiology of carbonic anhydrase enzymes is important. Co-trimoxazole.

Isoniazid, Azathioprine, Prednisolone, Cyclophosphamide, Ciclosporin, Mycophenolate, Sirolimus are the drugs which are commonly used against daibetic kidney disease. 

                                                    Conclusion:

This report sheds light on diabetic kidney disease. Diabetes has been termed as one of the major factors for development of chronic kidney disease. Diabetes is quite commonplace in today’s world, and adoption of sedentary lifestyle, adherence to poor dietary regimen have contributed largely to development of diabetes and diabetes associated kidney disease. Diabetes kidney disease can have fatal consequences that encompasses cardio vascular stroke, renal dysfunction, dementia, etc. These fatalities if left unaddressed can be life threatening, The major signs and symptoms of Diabetic kidney disease have been articulated in this report, along with the risk factors and associated complications. The different ways of prevention o diabetic kidney disease have been entailed along with the treatment strategies which would increase the longevity of the patient and improve their health outcome. Acetazolamide is the best drug of choice for treating diabetic kidney disease. Metformin on the other hand can be administered to the client to improve their diabetes which would significantly lower the chances of kidney disease. To conclude it can be said that if proper precautions are taken to avoid diabetes, diabetes associated kidney disease and other complications can also be avoided.