1
The Effects of Obesity and Type II Diabetes on End Stage Kidney Disease
Name
College
Table of contents
Abstract...... page 3
Introduction...... page 4
Objectives...... page 9
Methods...... page 10
Results...... page 12
Discussion...... page 13
Conclusion...... page 15
Appendix...... page 17
References...... page 18
Abstract
According to the CDC 33.9% of adults from 2007-2008 were obese in America and the numbers continue to climb. The health effects of obesity include Type II diabetes and its complications, such as end stage kidney disease (ESKD). This study will evaluate the requirement for significant and life saving therapies in the form of kidney transplant or continual dialysis for patients with diabetes type II. The goal of this work will be the early warning of impending renal collapse in the selected patients who are at current high risk for the development of renal failure secondary to diabetes type II.
Introduction
Diabetes can affect many parts of the body, including the kidneys. In healthy kidneys, many tiny blood vessels filter waste products from your body. The blood vessels have holes that are big enough to allow tiny waste products to pass through into the urine but are still small enough to keep useful products (such as protein and red blood cells) in the blood. High levels of glucose in the blood can damage these vessels if diabetes is not controlled. This can cause nephropathy, and if the damage is bad enough, the kidneys could stop working.
In some countries, diabetic kidney disease (DKD) is responsible for half of all new patients requiring renal replacement therapy (RRT). Understanding the relationship between early and later stages of DKD is important, as it is a preventable cause of renal failure (Hill, 2012). The burden of nephropathy is unequally shared across patients with diabetes. The majority of the variability in incident nephropathy remains unaccounted for by conventional risk factors. There appears to be an inherited predisposition for diabetic nephropathy, but this does not follow simple Mendelian rules. Any inherited predisposition for nephropathy is far more complicated (Thomas, 2012).
A few candidate genes have been reproducibly associated with diabetic nephropathy, and recent genome-wide linkage studies have also identified chromosomal loci for susceptibility genes, including 3q, 7q, 10p, 14q and 18q. Unbiased, genome-wide linkage studies have identified specific loci and genome-wide association studies a number of new loci. However, any roles of those genes in the molecular pathobiology remain to be established. Moreover, their individual contribution to the variability in incident nephropathy in diabetes appears to be small (Thomas, 2012).
It is clear that there is multiple factors that contribute to weight gain and the development of obesity. In fact, science shows that genetics does play a role in significant weight gain. However, genes do not always predict future health. Genes and behavior may both be needed for a person to be overweight. In some cases multiple genes may increase one's susceptibility for obesity and require outside factors, such as too high an intake of food as well as too little physical activity. In the past it was uncontrolled hypertension was the number one cause of renal failure, but now that America is so obese it could be that obesity and the resulting Type II diabetes that are resulting in the severe medical effects seen in many patients, such as end stage kidney disease (ESKD).
Chronic kidney disease (CKD) affects 26 million American adults and millions of others are still at an increased risk based on their lifestyle. Early detection can help prevent the progression of kidney disease to kidney failure later in life. Hypertension causes CKD and CKD causes hypertension, so it is a never ending and vicious cycle that perpetrates itself in the individual battling these issues. Presently hypertensive patients with CKD and diabetes are increasing in number, and cardiovascular complications are the most common cause of death in these hypertensive patients (Tamura, 2011). Glomerular filtration rate (GFR) is the best estimate of kidney function, and it is non-invasive to boot. Persistent proteinuria (protein in the urine) means that CKD is most likely present in the tested individual.
High-risk groups for CKD include those with diabetes, hypertension, and a family history of kidney disease. African Americans, Hispanics, Pacific Islanders, Native Americans and seniors are at advanced risk as well. Three simple tests can detect CKD: blood pressure, urine albumin, and serum creatinine (kidney.org). Your kidneys help to maintain your health by releasing hormones in to the blood to help regulate blood pressure, make new red blood cells, and promote strong bones (Kidney.org). Pregnant women are supposed to have a test for gestational diabetes during their pregnancy but not everyone does. Women who are diagnosed with the disease stand a 40 to 60 percent chance of developing type II diabetes within the next 5 to 10 years after giving birth (hudsonreporter.com).
It's well known that diabetes and hypertension are prevalent in the United States. However, many people don't realize these diseases are also the leading causes of CKD. During National Kidney Month in March, Fresenius Medical Care North America (FMCNA), the nation's leading network of dialysis facilities, urges people at risk for CKD to be aware of the symptoms of the disease and how to help slow its progression.
CKD is a progressive, usually permanent loss of kidney function. Many people who have CKD are still in the early stages of the disease, but by the time CKD leads to kidney failure, or end-stage renal disease (ESRD), the only viable treatments are a kidney transplant or dialysis. Some of the early symptoms of kidney disease include changes in urination; swelling of the face, hands and/or feet; feeling more tired than usual; nausea and vomiting; headache, dizziness; severe itching; shortness of breath; loss of appetite; and high blood pressure. In the early stages of kidney disease many people do not show any symptoms, which is why screening tests are so important. It is much better to know early if you have CKD because there are often interventions that can slow its progression.
The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is ACE inhibitor drugs, which usually reduces proteinuria levels and slows the progression of diabetic nephropathy. Several effects of the ACEIs that may contribute to renal protection have been related to the association of rise in Kinins that is also responsible for some of the side effects associated with ACEIs therapy such as dry cough. The renal protection effect is related to the antihypertensive effects in normal and hypertensive patients, renal vasodilatation resulting in increased renal blood flow and dilatation of the efferent arterioles. Many studies have shown that related drugs, angiotensin receptor blockers (ARBs), have a similar benefit. However, combination therapy, according to the ONTARGET study (Yusuf, 2008), is known to worsen major renal outcomes, such as increasing serum creatinine and causing a greater decline in estimated glomerular filtration rate (eGFR).
Blood-glucose levels should be closely monitored and controlled. This may slow the progression of the disorder, especially in the very early ("microalbuminuria") stages. Medications to manage diabetes include oral hypoglycemic agents and insulin injections. As kidney failure progresses, less insulin are excreted, so lesser doses may be needed to control glucose levels. Some people can live with kidney disease under a doctor's care for a long time before they reach end-stage kidney disease, while others progress more quickly. In either case, it's important to be compliant with your medical appointments and talk regularly with your healthcare team (Marketwatch.com).
Objectives
This study will evaluate the need for dialysis treatment after a prolonged period of diabetes type II. The work will determine the need for advanced treatment in the patients we study.
Methods
The study as proposed will investigate the impact of type II diabetes on the development of ESKD, and the resulting need for further or current dialysis treatment. The research study will recruit various members currently being treated for diabetes, specifically type II. The study will then evaluate, in a prospective manner, the development of ESKD. Furthermore, the research will consider how many of these patients currently need dialysis treatment for their kidney disease, as well as the amount they may need dialysis treatment in the future.
I intend to prospectively recruit 100 adult diabetic patients being treated at a local health clinic. This population will include both males and females, between the ages of 50 and 65 years of age. These 100 patients will be followed at the Fresenius Dialysis Clinic in Conyers, GA. The initial diagnosis of DM was based on either diabetic cause of ESRD or on reporting of diabetes as a co morbid diagnosis. Hemoglobin A1C will be checked over a 90-day period on patients with previously well-controlled blood sugars (controlled to be approximately 50%) and those with poorly controlled blood sugar levels (controlled to be approximately 50%). Records will be checked at the patients' home primary care physician or internal medicine office to determine who would qualify to participate in study. Patient demographic and case-mix variables will be collected, including age, gender, race, dialysis vintage, and body surface area. Finally, the patients will be checked for any confounding factors, such as previous history of kidney disease, alcohol or drug intake, and frequency of adequate water consumption.
Any individuals falling outside the normal parameters will be excluded from the study to limit confounders. The patient variables will be grouped into one of the following three categories: all patients in the study group; well controlled blood sugar results and Hemoglobin A1C under 7%; poorly controlled blood sugar results along with Hemoglobin A1C over 7%. This data will be analyzed for the need of kidney dialysis in each of the three groups as outlined above. The material will be evaluated using the chi-squared and student t-tests to determine variability of the results for the population studied, and the resulting need for dialysis treatment. The anticipated results are that the group with previously poor glucose control may need a statistically higher percentage of dialysis treatment secondary to kidney failure.
Results
The findings in this study will likely show that patients who have had significant diabetes type II with poor glucose control will need dialysis or kidney transplant at a higher rate than those with the same condition but who practiced good control of their glucose levels. We anticipate that the patients in this portion of the study will have significantly higher rates of morbid obesity and signs of severe kidney failure at the time of diagnosis.
Discussion
There is little doubt that the findings of this study will be imperative for the future health of patients with DM type II and progressing kidney disease. The emotional and physical tolls of these conditions are enormous, and anything that can help minimize future problems will be much appreciated.
It is unfortunate that the association between DM type II and diabetic nephropathy have been so clearly established. Nevertheless, this study is so important because anything that can help a patient avoid a lifetime of dialysis is a positive improvement. If this research can prove without a shadow of a doubt that tight glucose control can affect the need for kidney transplant or long term replacement therapy, it can save the patient and healthcare system millions of dollars in treatment and lost wages and continued care.
The findings of this study will provide a guideline for diabetic patients who wish to avoid the risks and expense of organ transplant or inconvenience of continual and lifelong dialysis. As there are few warning signs for preemptive improvements in kidney health, this work is but one more bullet in the arsenal to encourage patients to maintain their blood sugar levels in a reasonable range.
GFR is the best way to find out how well your kidneys are working. your doctor will begin by testing your blood for a waste product called creatinine. When the kidneys are damaged, they have trouble removing creatinine from your blood. Creatinine is stored in muscle tissue and blood. The blood test for creatinine will help your doctor find out how well your kidneys are working. But it is only the first step.
Next, your doctor or lab will take the result of this test and put it into a math formula that includes your age, race, and sex. The number that results from this math formula
is called your GFR (glomerular filtration rate). It tells your doctor how well your kidneys are working. Each diabetic patient should have this test at least once a year.
Once your GFR is known, your doctor can tell which stage of kidney disease you have. There are five stages of kidney disease (see the chart in the appendix). Each individual's specific treatment will depend on the stage of kidney disease that is present.
It is my hope that this work will contribute to the overall understanding of diabetes and its association with renal failure. These conditions are currently rampant in this country; I look forward to underscoring the importance of good glucose control in the management of diabetes and its complications.
Conclusion
The association between diabetes type II and the progression of kidney disease have been thoroughly established. However, the exact length of time to the production of diabetic nephropathy has not been so clearly proven. The clinical questions to be answered by this study will be the determination of the average years of having diabetes before it causes renal failure, and if there are any methods to improve this scenario.
Many individuals with diabetes realize that they are at risk for some kidney damage with long standing hyperglycemia; however, some people with diabetes type II progress to outright kidney failure after a period of time while others do not. A definitive length of time between the two occurrences does not yet exist in the literature. The goal of this work will be to put a more real timeline in place for the development of significant kidney disease and overt kidney failure with the concomitant presence of diabetes type II.
This study evaluated the clear need for intervention for kidney failure in patients with known diabetes type II, identified as the need for either a kidney transplant or continual kidney dialysis. The author of this research looks to improve the situation for many diabetics so that they may maintain their kidney function as long as possible without the need for extreme treatments.
In most cases, the progression of kidney failure from kidney disease comes without warning, and often necessitates prompt and life saving therapy aimed at preserving kidney function in an already sick individual. The combined use of GFR measurements as well as the documentation of worsening hyperglycemia by means of an H1Ac test will help to provide some premature indication of worsening kidney function with time, to give the patient a fighting chance to bring their glucose under better control.
Appendix
Table 1: Stages of Kidney Diseaseease
Stage / Description / GFR1 / Kidney damage with normal GFR / 90 or above
2 / Kidney disease with mild decrease in GFR / 60 to 80
3 / Moderate decrease in GFR / 30 to 59
4 / Severe reduction in GFR / 15 to 29
5 / Kidney failure / Less than 15
The GFR number tells the doctor how much kidney function that remains. As chronic kidney disease progresses, the GFR number decreases.
References
Chronic Kidney Disease retrieved from
CDC.gov
Fresenius Medical Care Offers Five Tips to Help Slow the Progression of Kidney Disease retrieved from
Hill, C. (2012) Changing trends in end-stage renal disease due to diabetes in the United kingdom. J Ren Care. 2012 Feb;38 Suppl 1:12-22.
Pope, G. (2012). Are you pregnant? Latina? Overweight? Hispanic women at greater risk for gestational diabetes; participants wanted fro program retrieved from
Tamura, K. (2011) Emerging concept of anti-hypertensive therapy based on ambulatory blood pressure profile in chronic kidney disease. Am J Cardiovasc Dis. 2011; 1(3): 236–243.
Thomas, M. (2012) Towards understanding the inherited susceptibility for nephropathy in diabetes. Curr Opin Nephrol Hypertens. 2012 Mar;21(2):195-202.
Yusuf, S. (2008). "Telmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events". New England Journal of Medicine358 (15): 1547–59.