Type II Diabetes and Kidney Failure: Type II Diabetes and Kidney Failure: Incidence and Prevalence Among Incidence and Prevalence Among

Culturally Diverse PopulationsCulturally Diverse Populations

• Joyce Newman Giger, Ed.D., APRN, BC, Joyce Newman Giger, Ed.D., APRN, BC, FAANFAAN

• Professor and Lulu Wolff Hassenplug Professor and Lulu Wolff Hassenplug Endowed ChairEndowed Chair

The Prevalence of Diabetes in The Prevalence of Diabetes in the United Statesthe United States

• 15.7 million people--5.9 percent of the population--have diabetes.

• Diagnosed: 10.3 million peopleUndiagnosed: 5.4 million people.

• Nearly 95% of diabetics in this country are Type 2 diabetics.

• Diabetes is the fifth deadliest disease in the United States, and it has no cure.

• The total annual economic cost of diabetes in 2006 was estimated to be $132 billion, or one out of every 10 health care dollars spent in the United States.

Type 2 DiabetesType 2 Diabetes

• Type 2 diabetesType 2 diabetes is the most is the most common form of diabetes.common form of diabetes.

• In In type 2 diabetestype 2 diabetes, either the body , either the body does not produce enough insulin does not produce enough insulin or the cells ignore the insulin. or the cells ignore the insulin.

Prevalence of Diabetes Prevalence of Diabetes (Continued) (Continued)

• In 2000, the prevalence rate for pre-In 2000, the prevalence rate for pre-menopausal AAW was twice as high as menopausal AAW was twice as high as their White counterparts (their White counterparts (50.950.9 compared with compared with 23.4 23.4 per per 100,000100,000). ).

• For Mexican American women, it was For Mexican American women, it was 37.2 compared with 37.2 compared with 23.423.4 per per 100,000100,000. .

Age Adjusted Death Rate for Age Adjusted Death Rate for DiabetesDiabetes

• The age-adjusted death rate The age-adjusted death rate from diabetes among AAW from diabetes among AAW ((25.4 25.4 per per 100,000100,000) was double ) was double that of their White counterparts that of their White counterparts ((9.69.6 per per 100,000100,000).).

Potential for Life Lost due to Potential for Life Lost due to DiabetesDiabetes

• In 2001, the estimated years of potential lost before the age of 50 for women with diabetes was 318.3 per 100,000 for AA women, 306.4 per 100,000 for American Indian/Alaskan Native women, 167.9 per 100,000 among Hispanics, and 111.1 per 100,000 for non-Hispanic White women.

• Insulin-dependent diabetes mellitus (IDDM) or Type I diabetes has a peak incidence between the ages of 10 and 14 years, apparently affects boys at a somewhat higher frequency than girls, has a higher incidence in Whites, and accounts for 10% to 20% of cases.

African Americans and DiabetesAfrican Americans and Diabetes

• African Americans are African Americans are affected affected disproportionately by disproportionately by diabetes and its diabetes and its complications. complications.

• Almost Almost 3 million3 million African African Americans have diabetes Americans have diabetes and are twice as likely as and are twice as likely as non-Hispanic whites to have non-Hispanic whites to have diabetes. diabetes.

• Approximately Approximately 2.7 million2.7 million or or 11.4%11.4% of all African Americans of all African Americans aged 20 years or older have aged 20 years or older have diabetes.  diabetes. 

• However, one-third of them do However, one-third of them do not know it. not know it.

PrevalencePrevalence

• African Americans are 1.6 times more African Americans are 1.6 times more likely to have diabetes than non-Latino likely to have diabetes than non-Latino whites. whites.

• 25%25% of African Americans between the of African Americans between the ages of ages of 65 and 7465 and 74 have diabetes. have diabetes.

• OneOne in in four four African American women African American women over over 55 years of age55 years of age has diabetes. has diabetes.

Kidney Failure and DiabetesKidney Failure and Diabetes

• Diabetes is the leading cause of Diabetes is the leading cause of kidney failure, accounting for kidney failure, accounting for 43% of new cases43% of new cases. .

• Ten to 21%Ten to 21% of all people with of all people with diabetes develop kidney diabetes develop kidney disease.disease.

Primary Causes of Kidney Primary Causes of Kidney FailureFailure

• Nearly 24 million people in the United States have diabetes, and nearly 180,000 people are living with kidney failure as a result of diabetes.Nearly 24 million people in the United States have diabetes, and nearly 180,000 people are living with kidney failure as a result of diabetes.

• .

• [Top]• Diagnosis of CKD• People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are eGFR and urine albumin.• eGFR. eGFR stands for estimated glomerular filtration rate. Each kidney contains about 1 million tiny filters made up of blood vessels. These filters are called glomeruli. Kidney function can be checked by estimating how much blood the glomeruli filter in a minute. The calculation of eGFR is based on the amount of creatinine, a waste product, found in a blood sample. As the level of creatinine goes up, the eGFR goes down.• Kidney disease is present when eGFR is less than 60 milliliters per minute.• The American Diabetes Association (ADA) and the National Institutes of Health (NIH) recommend that eGFR be calculated from serum creatinine at least once a year in all people with diabetes.• Urine albumin. Urine albumin is measured by comparing the amount of albumin to the amount of creatinine in a single urine sample. When the kidneys are healthy, the urine will contain large amounts of creatinine but almost no albumin. Even a small increase in the ratio of albumin to creatinine is a sign of kidney damage.• Kidney disease is present when urine contains more than 30 milligrams of albumin per gram of creatinine, with or without decreased eGFR.• The ADA and the NIH recommend annual assessment of urine albumin excretion to assess kidney damage in all people with type 2 diabetes and people who have had type 1 diabetes for 5 years or more.• If kidney disease is detected, it should be addressed as part of a comprehensive approach to the treatment of diabetes.• [Top]• Effects of High Blood Pressure• High blood pressure, or hypertension, is a major factor in the development of kidney problems in people with diabetes. Both a family history of hypertension and the presence of hypertension appear to increase chances of developing kidney disease. Hypertension also accelerates the progress of kidney disease when it already exists.• Blood pressure is recorded using two numbers. The first number is called the systolic pressure, and it represents the pressure in the arteries as the heart beats. The second number is called the diastolic pressure, and it represents the pressure between heartbeats. In the past, hypertension was defined as blood pressure higher than 140/90, said as “140 over 90.”• The ADA and the National Heart, Lung, and Blood Institute recommend that people with diabetes keep their blood pressure below 130/80.• Hypertension can be seen not only as a cause of kidney disease but also as a result of damage created by the disease. As kidney disease progresses, physical changes in the kidneys lead to increased blood pressure. Therefore, a dangerous spiral, involving rising blood pressure and factors that raise blood pressure, occurs. Early detection and treatment of even mild hypertension are essential for people with diabetes.• [Top]• Preventing and Slowing Kidney Disease• Blood Pressure Medicines• Scientists have made great progress in developing methods that slow the onset and progression of kidney disease in people with diabetes. Drugs used to lower blood pressure can slow the progression of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. Many people require two or more drugs to control their blood pressure. In addition to an ACE inhibitor or an ARB, a diuretic can also be useful. Beta blockers, calcium channel blockers, and other blood

pressure drugs may also be needed.• An example of an effective ACE inhibitor is lisinopril (Prinivil, Zestril), which doctors commonly prescribe for treating kidney disease of diabetes. The benefits of lisinopril extend beyond its ability to lower blood pressure: it may directly protect the kidneys’ glomeruli. ACE inhibitors have lowered proteinuria and slowed deterioration even in people with diabetes who did not have high blood pressure.• An example of an effective ARB is losartan (Cozaar), which has also been shown to protect kidney function and lower the risk of cardiovascular events.• Any medicine that helps patients achieve a blood pressure target of 130/80 or lower provides benefits. Patients with even mild hypertension or persistent microalbuminuria should consult a health care provider about the use of antihypertensive medicines.• Moderate-protein Diets• In people with diabetes, excessive consumption of protein may be harmful. Experts recommend that people with kidney disease of diabetes consume the recommended dietary allowance for protein, but avoid high-protein diets. For people with greatly reduced kidney function, a diet containing reduced amounts of protein may help delay the onset of kidney failure. Anyone following a reduced-protein diet should work with a dietitian to ensure adequate nutrition.• Intensive Management of Blood Glucose• Antihypertensive drugs and low-protein diets can slow CKD. A third treatment, known as intensive management of blood glucose or glycemic control, has shown great promise for people with diabetes, especially for those in the early stages of CKD.• The human body normally converts food to glucose, the simple sugar that is the main source of energy for the body’s cells. To enter cells, glucose needs the help of insulin, a hormone produced by the pancreas. When a person does not make enough insulin, or the body does not respond to the insulin that is present, the body cannot process glucose, and it builds up in the bloodstream. High levels of glucose in the blood lead to a diagnosis of diabetes.• Intensive management of blood glucose is a treatment regimen that aims to keep blood glucose levels close to normal. The regimen includes testing blood glucose frequently, administering insulin throughout the day on the basis of food intake and physical activity, following a diet and activity plan, and consulting a health care team regularly. Some people use an insulin pump to supply insulin throughout the day.• A number of studies have pointed to the beneficial effects of intensive management of blood glucose. In the Diabetes Control and Complications Trial supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), researchers found a 50 percent decrease in both development and progression of early diabetic kidney disease in participants who followed an intensive regimen for controlling blood glucose levels. The intensively managed patients had average blood glucose levels of 150 milligrams per deciliter—about 80 milligrams per deciliter lower than the levels observed in the

conventionally managed patients. The United Kingdom Prospective Diabetes Study, conducted from 1976 to 1997, showed conclusively that, in people with improved blood glucose control, the risk of early kidney disease was reduced by a third. Additional studies conducted over the past decades have clearly established that any program resulting in sustained lowering of blood glucose levels will be beneficial to patients in the early stages of CKD.• [Top]• Dialysis and Transplantation• When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney transplant. As recently as the 1970s, medical experts commonly excluded people with diabetes from dialysis and transplantation, in part because the experts felt damage caused by diabetes would offset benefits of the treatments. Today, because of better control of diabetes and improved rates of survival following treatment, doctors do not hesitate to offer dialysis and kidney transplantation to people with diabetes.• Currently, the survival of kidneys transplanted into people with diabetes is about the same as the survival of transplants in people without diabetes. Dialysis for people with diabetes also works well in the short run. Even so, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of diabetes—such as damage to the heart, eyes, and nerves.• [Top]• Good Care Makes a Difference• People with diabetes should• have their health care provider measure their A1C level at least twice a year. The test provides a weighted average of their blood glucose level for the previous 3 months. They should aim to keep it at less than 7 percent. • work with their health care provider regarding insulin injections, medicines, meal planning, physical activity, and blood glucose monitoring. • have their blood pressure checked several times a year. If blood pressure is high, they should follow their health care provider’s plan for keeping it near normal levels. They should aim to keep it at less than 130/80. • ask their health care provider whether they might benefit from taking an ACE inhibitor or ARB. • ask their health care provider to measure their eGFR at least once a year to learn how well their kidneys are working. • ask their health care provider to measure the amount of protein in their urine at least once a year to check for kidney damage. • ask their health care provider whether they should reduce the amount of protein in their diet and ask for a referral to see a registered dietitian to help with meal planning. • [Top]• Points to Remember• Diabetes is the leading cause of chronic kidney disease (CKD) and kidney failure in the United States. • People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are estimated glomerular filtration rate (eGFR) and urine albumin. • Drugs used to lower blood pressure can slow the progression of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. • In people with diabetes, excessive consumption of protein may be harmful. • Intensive management of blood glucose has shown great promise for people with diabetes, especially for those in the early stages of CKD. • [Top]• Hope through Research• The number of people with diabetes is growing. As a result, the number of people with kidney failure caused by diabetes is also growing. Some experts predict that diabetes soon might account for half the cases of kidney failure. In light of the increasing illness and death related to diabetes and kidney failure, patients, researchers, and health care professionals will continue to benefit by addressing the relationship between the two diseases. The NIDDK is a leader in supporting research in this area.• Several areas of research supported by the NIDDK hold great potential. Discovery of ways to predict who will develop kidney disease may lead to greater prevention, as people with diabetes who learn they are at risk institute strategies such as intensive management of blood glucose and blood pressure control.• Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.• The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.• [Top]• For More Information• National Diabetes Information Clearinghouse

1 Information WayBethesda, MD 20892–3560Phone: 1–800–860–8747TTY: 1–866–569–1162Fax: 703–738–4929Email: ndic@info.niddk.nih.govInternet: www.diabetes.niddk.nih.gov

• National Diabetes Education Program1 Diabetes WayBethesda, MD 20892–3560Phone: 1–800–438–5383TTY: 1–866–569–1162Fax: 703–738–4929Email: ndep@mail.nih.govInternet: www.ndep.nih.gov

• National Kidney Disease Education Program3 Kidney Information WayBethesda, MD 20892Phone: 1–866–4–KIDNEY (454–3639)Email: nkdep@info.niddk.nih.govInternet: www.nkdep.nih.gov

• American Diabetes Association1701 North Beauregard StreetAlexandria, VA 22311Phone: 1–800–342–2383Email: AskADA@diabetes.orgInternet: www.diabetes.org

• National Kidney Foundation30 East 33rd StreetNew York, NY 10016Phone: 1–800–622–9010 or 212–889–2210Fax: 212–689–9261Internet: www.kidney.org

• The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) collects resource information about kidney and urologic diseases for the NIDDK Reference Collection. This database provides titles, abstracts, and availability information for health information and health education resources.• You may view the results of the automatic search on kidney disease of diabetes. If you wish to perform your own search of the database, go to NIDDK Reference Collection.• This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (463–6332) or visit www.fda.gov. Consult your doctor for more information.• [Top]• National Kidney and Urologic Diseases Information Clearinghouse• 3 Information Way

Bethesda, MD 20892–3580Phone: 1–800–891–5390TTY: 1–866–569–1162Fax: 703–738–4929Email: nkudic@info.niddk.nih.govInternet: www.kidney.niddk.nih.gov

• The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1987, the Clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, health care professionals, and the public. The NKUDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about kidney and urologic diseases.

• In In 2000,2000, 41,046 41,046 people with people with diabetes initiated treatment for diabetes initiated treatment for kidney failure, and 129,183 kidney failure, and 129,183 people with diabetes underwent people with diabetes underwent dialysis or kidney dialysis or kidney transplantation. transplantation.

African Americans , Diabetes, and African Americans , Diabetes, and Kidney FailureKidney Failure

• African Americans with African Americans with diabetes are diabetes are 2.6 to 5.62.6 to 5.6 times times more likely to suffer from more likely to suffer from kidney disease.kidney disease.

Chronic Kidney FailureChronic Kidney Failure

• Even when diabetes is Even when diabetes is controlled, the disease can controlled, the disease can lead to CKD lead to CKD (Chronic Kidney (Chronic Kidney Disorder)Disorder) and kidney failure. and kidney failure.

• Most people with diabetes Most people with diabetes do not develop CKD that is do not develop CKD that is severe enough to progress severe enough to progress to kidney failure. to kidney failure.

• Researchers have found that high Researchers have found that high blood pressure and high levels of blood blood pressure and high levels of blood glucose increase the risk that a person glucose increase the risk that a person with diabetes will progress to kidney with diabetes will progress to kidney failure.failure.

• African Americans, American African Americans, American Indians, and Hispanics/Latinos Indians, and Hispanics/Latinos develop diabetes, CKD, and develop diabetes, CKD, and kidney failure at rates higher kidney failure at rates higher than Caucasians. than Caucasians.

• Scientists have not been able to explain Scientists have not been able to explain these higher rates. Nor can they explain these higher rates. Nor can they explain fully the interplay of factors leading to fully the interplay of factors leading to kidney disease of diabetes—factors kidney disease of diabetes—factors including heredity, diet, and other including heredity, diet, and other medical conditions, such as high blood medical conditions, such as high blood pressure.pressure.

• Most U.S. citizens who develop kidney Most U.S. citizens who develop kidney failure are eligible for federally funded failure are eligible for federally funded care. In 2005, care for patients with care. In 2005, care for patients with kidney failure cost the United States kidney failure cost the United States nearly $32 billion.nearly $32 billion.

• Most U.S. citizens who develop Most U.S. citizens who develop kidney failure are eligible for kidney failure are eligible for federally funded care. In 2005, federally funded care. In 2005, care for patients with kidney care for patients with kidney failure cost the United States failure cost the United States nearly nearly $32 $32 billion.billion.

The Course of Kidney DiseaseThe Course of Kidney Disease

• Diabetic kidney disease takes many Diabetic kidney disease takes many years to develop. years to develop.

• In some people, the filtering function of In some people, the filtering function of the kidneys is actually higher than the kidneys is actually higher than normal in the first few years of their normal in the first few years of their diabetes.diabetes.

• Over several years, people who are Over several years, people who are developing kidney disease will have developing kidney disease will have small amounts of the blood protein small amounts of the blood protein albumin begin to leak into their urine. albumin begin to leak into their urine.

Chronic Kidney Disease and Chronic Kidney Disease and DiabetesDiabetes

• This first stage of CKD is called This first stage of CKD is called microalbuminuria. microalbuminuria.

• The kidney’s filtration function The kidney’s filtration function usually remains normal during this usually remains normal during this period.period.

Chronic Kidney Disease and Chronic Kidney Disease and Diabetes (Continued)Diabetes (Continued)

• As the disease progresses, more As the disease progresses, more albumin leaks into the urine. albumin leaks into the urine.

• This stage may be called This stage may be called macroalbuminuria or proteinuria. macroalbuminuria or proteinuria.

• As the amount of albumin in the urine As the amount of albumin in the urine increases, the kidneys’ filtering increases, the kidneys’ filtering function usually begins to drop. function usually begins to drop.

Chronic Kidney Disease and Chronic Kidney Disease and Diabetes (Continued)Diabetes (Continued)

• The body retains various wastes as The body retains various wastes as filtration falls. filtration falls.

• As kidney damage develops, blood As kidney damage develops, blood pressure often rises as well.pressure often rises as well.

• Overall, kidney damage rarely occurs in Overall, kidney damage rarely occurs in the first 10 years of diabetes, and the first 10 years of diabetes, and usually 15 to 25 years will pass before usually 15 to 25 years will pass before kidney failure occurs. kidney failure occurs.

Chronic Kidney Disease and Chronic Kidney Disease and Diabetes (Continued)Diabetes (Continued)

• For people who live with diabetes for For people who live with diabetes for more than 25 years without any signs more than 25 years without any signs of kidney failure, the risk of ever of kidney failure, the risk of ever developing it decreases.developing it decreases.

Nutrition and Kidney FailureNutrition and Kidney Failure

• A high prevalence of malnutrition A high prevalence of malnutrition exists in patients with renal failure.exists in patients with renal failure.

• Indicators of nutrition status including Indicators of nutrition status including reduced nutrientreduced nutrient

• intake and muscle mass are each intake and muscle mass are each independently.independently.

• Several surveys have reported protein-Several surveys have reported protein-calorie malnutrition in up to 40% of thiscalorie malnutrition in up to 40% of this

patient population (Mehrotra, et al., patient population (Mehrotra, et al., 2001).2001).

• Malnutrition in renal failure Malnutrition in renal failure is multifactorial, but surveys is multifactorial, but surveys consistently report consistently report inadequate oral intake as a inadequate oral intake as a major contributing factor major contributing factor (Mehrotra, et al., 2001)(Mehrotra, et al., 2001)

• Research suggests that Research suggests that addressing GI issues in addressing GI issues in patients with renal failure patients with renal failure may improve nutritional may improve nutritional status.status.

• Although the traditional surrogate Although the traditional surrogate markers of malnutrition, such as markers of malnutrition, such as decreased muscle mass or serum decreased muscle mass or serum proteins have been associated with proteins have been associated with increased mortality, research is increased mortality, research is ongoing to determine if improving ongoing to determine if improving nutritional status will alter patient nutritional status will alter patient outcomes. outcomes.

• Decreased muscle mass or serum proteins can also be attributed to activation of the acute-phase response related to co-morbid conditions.

• In addition, it is possible that In addition, it is possible that co-morbid conditions result in co-morbid conditions result in increased inflammatory increased inflammatory cytokines and are the cause of cytokines and are the cause of both malnutrition and the both malnutrition and the increasedincreased

mortality. mortality.

• However, there are several studies However, there are several studies that demonstrate that the provision that demonstrate that the provision of increased nutrition to patients of increased nutrition to patients with malnutrition and renal failure with malnutrition and renal failure may improve patient.may improve patient.

• Gastrointestinal complaints Gastrointestinal complaints are frequently seen in this are frequently seen in this patient population and likely patient population and likely contribute to decreased contribute to decreased intake and malnutrition intake and malnutrition intake and malnutrition.intake and malnutrition.

Diabetes as a Health Disparity: Diabetes as a Health Disparity: Communicating Cultural Differences in Communicating Cultural Differences in

TreatmentTreatment

• African Americans, Latinos, and American Indians experience a 50% to 100% higher burden of illness and mortality due to diabetes than White Americans, yet the disease appears to be more poorly managed among ethnic minority patients.

• One study found that even after controlling for patients’ gender, education, and age, African Americans were less likely to undergo measures of glycosylated hemoglobin, lipid testing, or ophthalmologic visits than their White counterparts.

The Cultural Communication of The Cultural Communication of the need for Diabetic Awarenessthe need for Diabetic Awareness

• Communication and culture are closely intertwined.

• Without doubt, diabetes is expected to reach epidemic proportions in the next 10 years (rising to more than 22 million truly diagnosed cases). This figure will not include children and adolescents with diabetes.

• Many Ethnic minorities with diabetes do not understand the grave complications associated with diabetes.

• Diabetes without doubt strikes ethnic minorities in an way that makes it;

• Unequal• Unnecessary• Unpredictable if not treated.

• The best treatment for diabetes is PREVENTION.