Last week we discussed the complication of diabetic retinopathy – one of the major causes of blindness around the world.  Today we will discuss diabetic nephropathy and renal failure.  Diabetic kidney disease is the major cause of kidney failure.

ALSO READ : Turning the Tide – Understanding Diabetes (part 6)

According to a review of diabetic nephropathy in Africa: “Diabetic nephropathy (DN) is one of the most common complications of diabetes. The prevalence of DN is increasing steeply along with the diabetes epidemic. Approximately one third to half of patients with diabetes develop renal manifestations. DN is associated with increased premature mortality, end-stage renal disease and cardiovascular diseases, and escalating health-care costs.”

Some of the other facts discussed in the article:

• There is a strong genetic association with diabetic nephropathy
• Low socio-economic factors contribute to higher risk
• Diet is a strong contributor
• Poor hypoglycaemic control increases the risk
• The presence of hypertension is a stronger correlate of DN amongst black people than other race groups
• Obesity also shows strong correlation.
• There is a higher incidence of chronic kidney disease (CKD) in diabetics in Africa compared to Western society – prevalences vary between 11% and 84% depending on the method of assessment.
• Estimates suggest 95% of diabetics in Africa may have proteinuria after 10 years of diabetes
• About 35% may have end-stage renal disease after 5 years
• 18% die from nephropathy after 20 years of disease duration.

What is done for end-stage renal disease?

South Africa has the best facilities for management of end-stage renal disease (ESRD) in Africa, but there are still thousands of sufferers who are not able to access management because of cost or availability.  The two options are renal dialysis and/or renal transplant.  In 2016 only 10,257 people in S Africa were able to access this, and the vast majority of facilities offering this service were in the private sector.

There are times when renal dialysis can allow time for healing to take place, but this usually occurs in patients with non-diabetic nephropathy. 

In most patients with diabetes causing ESRD, the commonly accepted belief is that it is progressive, even with good management of diabetes.  The only difference is the rate of progress with better control slowing down that rate.

What causes diabetic nephropathy?

The most important contributor is high levels of blood sugar causing damage to small blood vessels in the kidney.  However diabetes is also known to cause atherosclerosis of the major blood vessels feeding the kidneys.  High blood pressure also damages the blood vessels in the kidneys, but kidney damage in return can increase blood pressure, so it can be a vicious cycle.

How do we know if the kidneys are being affected? 

In most people the deterioration of kidney function goes unnoticed.  That is why regular screening is important.  Some of the signs and symptoms include swelling of ankles, hands and face, passing urine more frequently, fatigue, persistent itching, nausea and vomiting, confusion or difficulty concentrating, less need for diabetic medications, worsening blood pressure – and then on the laboratory side protein in the urine.

Blood tests of kidney function are the most important way of establishing the level of kidney damage..

Phosphates and kidney disease

Phosphates are often added to processed foods like dairy, cereals and fizzy drinks.  This phosphate can contribute to vascular damage and thus progression of chronic kidney disease.  Phosphate is often added to processed meats and especially colas.  According to Dr Dean Ornish, artificial phosphate is absorbed differently to naturally occurring phosphate and can contribute to excess amounts in the bloodstream.

ALSO READ : Turning the Tide – Understanding Diabetes – what are the complications?

All proteins contain phosphates, but interestingly phosphates from animal proteins are absorbed more readily than phosphates in plant proteins.  Patients with chronic kidney disease are normally advised to reduce proteins, but the above findings suggest that if they use plant based foods, there is less risk.  Secondly, animal proteins tend to cause excess acid, which requires neutralisation by buffering with calcium taken from the bones, leading to calcium loss.

This above information has been obtained from an article produced by Dr Ornish’s Lifestyle Program.

Can chronic kidney disease be reversed? 

Here is an article by the USA National Kidney Foundation which discusses the advantages of a whole-food plant-based diet in the management of kidney disease.

However they seem reluctant to go as far as promoting a low-fat diet, which many researchers have shown to promote far better control of diabetes, as well as cardio-vascular disease.

Here is a personal story of someone who refused to accept her fate and discovered how to reverse her stage 3 diabetic nephropathy to the point where her nephrologist said he no longer needed to see her!  The article also discusses some of the problems with standard dietary intervention and why a low-fat whole-food plant-based diet is the superior way to manage both diabetes and diabetic nephropathy.

Although the above story gives hope of potential reversal, that may not be possible in most patients with severe kidney disease.  But there is much one can do to arrest the progress through lifestyle interventions. Prevention is much better than cure.

So what have we learned about chronic kidney disease and diabetes?

• Diabetes is one of the major causes of chronic kidney disease
• It is important to have regular checks of kidney function as well as to control diabetes as much as possible with adequate medical care
• Facilities for treating end-stage renal failure in South Africa are grossly inadequate, especially in the State sector, for managing the increasing number of patients with end-stage kidney failure.
• Dietary intervention is important to help to control diabetes
• A low-fat, whole-food plant-based diet has been shown in many studies to offer the best chance of controlling and even reversing diabetic nephropathy. This same diet has also been shown to be able to reverse diabetes in most patients, as well as reverse cardio-vascular disease.

Next week we will discuss diabetic neuropathy – also the most common cause of peripheral neuropathy.

To learning outside of the box,

Dave Glass

David Glass graduated from UCT in 1975. He spent the next 12 years working at a mission hospital in Lesotho, where much of his work involved health education and interventions to improve health, aside from the normal busy clinical work of an under-resourced mission hospital.

He returned to UCT in 1990 to specialise in obstetrics/gynaecology and then moved to the South Coast where he had the privilege of, amongst other things, ushering 7000 babies into the world. He no longer delivers babies but is still very clinically active in gynaecology.

An old passion, preventive health care, has now replaced the obstetrics side of his work. He is eager to share insights he has gathered over the years on how to prevent and reverse so many of the modern scourges of lifestyle – obesity, diabetes, ischaemic heart disease, high blood pressure, arthritis, common cancers, etc.

He is a family man, with a supportive wife, and two grown children, and four beautiful grandchildren. His hobbies include walking, cycling, vegetable gardening, bird-watching, travelling and writing. He is active in community health outreach and deeply involved in church activities. He enjoys teaching and sharing information.

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