Stephen J. Schueler, M.D.

Overview Incidence Risk Factors Symptoms Evaluation Treatment questions for doctor specialist Home Care diabetes diet kidney diet self monitoring taking control warning signs Complications Underlying Cause Anatomy

Diabetic Kidney Disease Home Care

Home care for diabetic nephropathy includes:

  • Follow your diabetic diet.
  • Do not drink alcohol.
  • Stop smoking.
  • Avoid exposure to secondary smoke.
  • Follow an exercise plan developed with your doctor.
  • Get regular checkups for your diabetes, including eye and foot exams.
  • Monitor your blood sugar:
    • Check your blood sugar every day.
    • Keep a log of your results.
    • Notify your doctor if your blood sugar remains higher than usual.
  • If you have high blood pressure:
    • Learn how to take your blood pressure.
    • Check your blood pressure every day.
    • Keep a log of your results.
  • Weight loss if you are overweight
  • Patients should be advised to avoid nonsteroidal anti-inflammatory medications, aspirin, and other medications that are metabolized by the kidney.
    • Acetaminophen can be used for pain because it is not metabolized by the kidneys.
  • Take your diabetes medications as directed:
    • Don't skip doses of your medication. This makes them less effective.
    • Avoid running out of your medication. Refill your prescriptions early.
    • Don't stop taking your medication just because you feel better.
    • If you feel worse, talk to your doctor before you stop your medication.
    • Be aware of the common side effects that may be caused by your medication.
    • Do not stop prescription medications without talking to your doctor.
  • Learn everything you can about diabetic nephropathy:
    • The more you know about your condition, the easier it will be to participate with your doctor in making treatment decisions.
    • Ask your doctor about good sources for information.
    • Write down questions to ask your doctor

Example of Sliding Scale Insulin Dosing
Glucose ReadingRegular Insulin Dosing
140 - 1602 units, re-check glucose in 2 hrs
200 - 2404 units, re-check glucose in 2 hrs
240 - 3006 units, re-check glucose in 2 hrs
300 - 4008 units, re-check glucose in 2 hrs
400 - 50010 units, re-check glucose in 2 hrs
> 500See doctor now!

Diabetic Kidney Disease Diabetes Diet

It is important to follow a healthy diet if you have diabetic nephropathy.

Total Calories
Your daily intake of calories should allow you to maintain a healthy weight. Total calorie requirements vary according to your weight, height and activity. Your doctor and dietitian will recommend a total daily calorie requirement that is right for you.

Carbohydrates
Carbohydrates should account for 55-60% of your total calories. Carbohydrates include sugars, starches, and fiber. Whole grains, fruits, vegetables and fiber, are better sources of carbohydrate than sugars. Dietary fiber has been shown to prevent constipation, reduce the risk of colon cancer and reduce cholesterol levels. A healthy diet contains 20-35 grams of fiber per day.

Protein
Protein should account for 10-20% of your total calories. Those who have normal kidneys should consume about 50 to 60 grams of protein per day. Those who have kidney disease should consume no more than 45 grams of protein per day.

Total Fat
Fat should account for less than 30% of your total calories. Consume only unsaturated fats that are low in cholesterol. About 10% to 15% of your total calories should be in the form of monounsaturated fats, such as olive oil, canola oil and peanut oil. Cholesterol intake should be limited to less than 300 milligrams per day.

Sweeteners
Consider replacing sugar with artificial sweeteners. Saccharin (Sweet-n-Low), aspartame (Equal), and sucralose (Splenda) are acceptable alternatives.

Sodium
Sodium intake should not exceed 3,000 mg per day. Those who have high blood pressure, heart disease, kidney disease or liver disease should consume no more than 2,000 mg of sodium per day.

Vitamins and Minerals
Diabetes does not require vitamin or mineral supplements.

Alcohol
Alcohol should be limited to two drinks per day.

Diabetic Kidney Disease Kidney Diet

A person with diabetic nephropathy may benefit from a kidney disease diet.

Kidney Disease Diet
A person with advanced kidney disease may need to avoid some foods and limit the amount of others. Waste products that failing kidneys cannot handle include protein, sodium, potassium, and phosphorus.

General Dietary Restrictions
When the kidneys are not working normally, waste products (blood urea nitrogen), the result of what we eat, build up in the bloodstream. Kidney dialysis (kidney machine) removes part of these byproducts temporarily until, once again, they accumulate. It is important for both the patient who is dependent upon dialysis, or suffering from compromised kidney function, to follow a carefully outlined diet. Typical dietary restrictions will be placed on total calories, fluids, protein, sodium, phosphorus, and potassium. Supplemental calcium is also required by many patients.

Calories
Calories are a measurement of the energy value of food. They are an essential part of any diet. The number of calories you eat affects your ability to gain and lose weight. An inadequate number of calories will burn protein derived not only from the protein that you eat, but also from the body's own muscle stores. A healthy diet must give your body both the required amount of protein for tissue growth and repair, as well as enough calories for your energy needs. Excess calories and protein will put an unnecessary strain on a diseased kidney.

Fluids
When the kidneys are no longer functioning efficiently, fluids accumulate in the body. Fluid overload can contribute to shortness of breath, hypertension, and swelling of the hands, legs, and feet. This condition can lead to congestive heart failure and excess build up of fluid in the lungs. Fluids are defined as all liquids, including all foods that melt to a liquid at room temperature. Since fluid overload is dangerous, it is important to limit your intake. Keeping track of your weight every day can allow you to early detect any trend of fluid retention.

Sodium
The balance of fluid in the human body is partly regulated by the mineral sodium. When sodium is combined with chloride, it forms table salt. Excessive amounts of salt in the diet result in the retention of too much water. This may cause a sudden increase in weight, swelling of the tissues and joints, high blood pressure, shortness of breath, and congestive heart failure. Most foods contain sodium either naturally or as additives. High sodium foods include processed and smoked meats, foods with salt toppings such as chips or nuts, sauces, and prepared and canned foods.

Many kidney disease patients must limit their sodium intake to 2 grams per day or less.

Potassium
The mineral potassium plays a key role in the normal functioning of the muscles and nerves as well as in regulating the pumping action of the heart. Muscle weakness and cardiac arrhythmias may be the result of high levels of potassium in the blood. Since the heart is a muscle, a buildup of potassium may lead to sudden death (cardiac arrest). Potassium is found in almost all foods and in salt substitutes. Your potassium level should be monitored closely. A dangerously high blood potassium level in a patient with end-stage kidney disease is a criterion for emergent kidney dialysis.

Protein
The body uses protein for the growth and repair of tissues. Normally, protein byproducts are excreted from the body in the urine. When kidney function is impaired, the end product of protein metabolism, urea, accumulates in the bloodstream. The best kind of protein to eat is the kind that is used most efficiently by the body. Doing this leaves the least amount of protein waste behind. These proteins are referred to as complete or high quality proteins that contain all the essential amino acids. High quality proteins include eggs, meat, fish, fowl, and some dairy products. Low quality proteins are found in foods such as vegetables, fruits, breads, cereals, and starches.

Calcium and Phosphorus
The balance of calcium and phosphorus in the body is crucial to the maintenance of healthy bones, muscles, and nerves. Renal disease contributes to the imbalance of these important minerals. Too much phosphorus may cause the bones to become brittle and break easily. This results from the body's removal of calcium in the bones to balance the excess phosphorus. Foods high in phosphorus are usually also high in potassium (another mineral that must be restricted). Phosphorus rich foods are dairy products, meats, shellfish, bran, whole grain products, beans, nuts, and chocolate. Calcium is found in most dairy products, but will need to be supplemented (OS-CAL) in most cases.

Vitamins and Minerals
Vitamin and mineral supplements such as (OS-CAL) are frequently needed since dietary restrictions may prevent a renal patient from receiving all the needed nutrients necessary for a healthy and balanced diet. Kidney dialysis can also remove vitamins from the bloodstream. Vitamin supplements should only be prescribed by a physician in patients with kidney disease.

Diabetic Kidney Disease Self Monitoring

An important part of the successful management of diabetic nephropathy is close monitoring of blood sugar.

Blood Testing for Glucose

  • Monitor your blood glucose as directed.
  • Learn to use your glucose monitor correctly.
  • Daily home glucose monitoring is essential.
    • Try to keep your glucose level before meals between 70-110 mg/dl.
    • Two hours after meals, your glucose level should be less than 140 mg/dl.
  • Check your blood sugar before operating a motor vehicle. Raise your blood sugar level by eating, if it falls below 70 mg/dl.
  • Carefully monitor your blood sugars when you are ill. Blood glucose increases when you are ill or have an infection.

When to test your blood glucose:
  • Before meals
  • Before bedtime
  • 1-2 hours after meals
  • 2-3 A.M., at least one night per week

Other reasons to test:

Urine Testing for Ketones
In the past, urine testing was very useful and important. With the advent of rapid blood sugar testing, urine testing is rarely performed. The main reason to perform this test is to check for early ketoacidosis. Small or trace ketones may mean nothing, or represent the beginning of ketoacidosis. If you find this result, then perform the ketone test again in several hours. Notify your physician immediately if you have moderate to large ketones in your urine.

Diabetic Kidney Disease Taking Control

The successful treatment of diabetic nephropathy requires your participation. Here are answers to some important questions.

Do you have control over your health and wellness?
Many people believe they have no control over their health and wellness. Many ignore personal health decisions or simply leave them to their doctors, relatives, or friends. In reality, you have the greatest potential to determine your relative health.

How is this possible? Do people really have control of their own health? The biggest killers are heart disease and cancer. Although many of these diseases seem to strike at random, our lifestyle choices greatly influence personal risk.

How can you participate in your health care?
To participate you must:

  • Learn to take responsibility for your own health.
  • Learn to partner with your doctor.
  • Learn how to make active decisions about your health.

How can you learn what you need to know?
  • Educate yourself.
  • Be skeptical: Learn to separate fact from fiction.
  • Billions of dollars are spent each year marketing dietary supplements, vitamins, and new medical treatments. Much of this is unnecessary and wasteful.
  • Be careful about where you get your health information.
    • Some of the best sources for health information on the web are professional societies and non-profit organizations.
    • Ask your doctor what he or she recommends.
  • Examine the credentials of the authors.
    • If you are reading about symptoms and disease, your best source is a licensed physician.
    • Pay attention to when the content was last updated.
    • Make sure the person is not just trying to sell you something.

Important questions you need to answer:
  • What things in your control can increase your risk for disease?
  • What can you do to decrease this risk?
  • What are vaccines and how can they help you?
  • How do your lifestyle choices increase your risk for disease?
  • How can you reduce stress?
  • What minor health problems can you treat at home?
  • When is a medical problem "serious"?
  • When should you call the doctor?

How can you find the right doctor?
Key points:
  • Everyone should have a primary care physician or family doctor. A primary physician is usually a family practitioner, internist, or pediatrician.
  • Establish a relationship in advance with your doctor.
  • Make sure you are comfortable with your primary care physician.
  • The internet contains many resources where you can do research to locate the doctor that is best for you.
  • You may wish to schedule a brief visit with the doctor to see if he or she is right for you.
    • Be open-minded, and allow your doctor to know you well. This will improve communication.

Important information you need to make your decision:
  • Physician credentials:
    • Internship and residency training is usually best from respected institutions, universities, and major hospitals.
    • Look for board certification in the specialty.
    • Ask about membership in medical societies.
  • Community and professional reputation are also important.
    • Are other patients happy with the doctor?
    • Has the doctor been disciplined by hospitals or agencies?
    • How long has the doctor been in practice?
    • In general, more than a few malpractice suits over a 5-10 year period should trigger caution.
  • Does the doctor communicate well? Are your questions answered during busy times?
  • Does the doctor welcome you to help make decisions about your care?
  • Is the doctor available when you need care?
  • What is the doctor's after-hours coverage?
  • Is he or she a member of a large group?
    • Do the doctors' cross-cover one another?
  • Where do they admit patients?

What is shared decision making?
You and your doctor must work together to jointly decide the best course of action to manage your health. This process is called "shared decision making". Your doctor becomes a guide and teacher and helps steer you toward the best treatment. Most doctors welcome this partnership. You must learn about your illnesses for shared decision-making to work.

For any recommended test, medication, or surgery, remember to ask:
  • How will this help me?
  • How much will it cost?
  • Is it covered by your insurance?
  • What are the potential side effects and risks?
  • What are my alternatives?

For tests, remember to ask:
  • Is it done in the office or at another facility?
  • Is it painful?
  • How will the results of this test influence my care?

For surgery or other procedures, remember to ask:
  • How long will it take to heal?
  • How many cases has the doctor done?
  • What would your doctor do if he or she were the patient?
  • Where is it done?
  • Who will perform it?
  • What are the doctor's qualifications?

What should you expect?
Shared decision making becomes impossible if you do not know what to expect from your doctor.

The American Hospital Association has published a "Patient's Bill of Rights" that is a good guide. It states that you have the right:
  • To be spoken to in words that you understand
  • To be told what's wrong with you
  • To know the benefits of any treatment and any alternatives
  • To know what a treatment or test will cost
  • To share in treatment decisions
  • To read your medical record
  • To refuse any medical procedure

What should you do before an office visit?
  • Bring all important medical information with you to the visit.
  • Make sure you can answer questions about the following:
    • Allergies and side effects to medicines
    • Current medicines you are taking. This includes herbs and vitamins. Make a list if necessary.
    • Insurance information
    • Marital and sexual history
    • Past injuries and hospital stays
    • Past medical problems
    • Past surgeries and operations
    • Pre-visit questionnaires
    • Use of tobacco, alcohol and drugs
    • Work history

What should you expect from the visit?
  • You should plan to wait if you go without an appointment. Emergencies or sick patients in the hospital may interrupt your doctor.
  • Bring along a book or toys for the kids. You may also have to wait during busy times.
  • Tell your doctor about your problem in a clear manner. Start from the beginning and go through each symptom as it appeared.
  • Before the visit, think about what makes your problem better or worse. Your doctor will probably ask you questions about this.
  • Most doctors ask many questions about unrelated symptoms. These questions help assure that there are no other problems that need attention.
  • Be sure to answer all questions truthfully. This includes sensitive questions about smoking, drug use, sexual activity, and work. Your history is the most important part of deciding what is wrong with you.
  • If you have any difficulty communicating your concerns, bring a family member or friend to assist in this task.
  • Talk to your doctor and do not leave the office without asking necessary questions. Your doctor can make you more comfortable if he or she understands your concerns.

What should you know about your medications?
Every year many people become ill because of problems with medications.

Remember to ask:
  • What side effects to expect.
  • What drug interactions are possible.
    • Find out if a new medicine reacts with those that you are taking now.
    • Many over-the-counter drugs and dietary supplements can also cause serious side effects and drug interactions.
    • Some drugs interact with certain foods, vitamins, nicotine, and alcohol.
  • Make sure you can drive or operate machines safely while taking a medicine.
  • Ask your doctor how much a prescription costs.
    • Is there a less expensive option or a generic version?

What is a treatment plan?
A treatment plan is what you and your doctor decide to do for an illness. A treatment plan cannot be effective without your participation.

Three simple questions can help you get the most from your treatment plan:
  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do these things?

Other important points:
  • Be sure you understand your treatment plan.
  • Stick with the treatment plan and allow time for improvement.
  • Don't stop medicines when you feel better; check with your doctor first.
  • Call your doctor if your condition is becoming worse.
  • Your doctor should tell you what to expect and when to follow-up or call the office.

Diabetic Kidney Disease Warning Signs

Continue to Diabetic Kidney Disease Complications

Last Updated: Feb 15, 2011 References
Authors: Stephen J. Schueler, MD; John H. Beckett, MD; D. Scott Gettings, MD
Copyright DSHI Systems, Inc. Powered by: FreeMD - Your Virtual Doctor

PubMed Diabetic Kidney Disease References
  1. Olson DE, Norris SL. Diabetes in older adults. Overview of AGS guidelines for the treatment of diabetes mellitus in geriatric populations. Geriatrics. 2004 Apr;59(4):18-24. [15086070]
  2. Shlipak M. Diabetic nephropathy. Clin Evid. 2004 Dec;(12):814-33. [15865682]
  3. Thorp ML. Diabetic nephropathy: common questions. Am Fam Physician. 2005 Jul 1;72(1):96-9. [16035688]
  4. Wittmann I, Molnar GA, Degrell P, et al. Prevention and treatment of diabetic nephropathy. Diabetes Res Clin Pract. 2005 Jun;68 Suppl1:S36-42. [15955373]
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