Diabetes management in chronic kidney disease patients


Diabetes can also be generalized as excessive sugar or glucose in the blood than the normal levels. There are various causes and types of diabetes. Patients with CKD are more likely to develop hyperglycemia due to abnormal filtration or abnormal pancreatic activity of the body. Insulin is the hormone that counteracts the glucose in the blood. Glucagon is another hormone that counteracts insulin. Glucose more than 200mg is considered diabetic or also Hba1c more than 6.5. Insulin is washed off from the body by the bean like organs that is kidneys and this hence shows the relationship between renal disorder and diabetes.

How is CKD responsible for diabetes?

CKD is a condition where GFR is below 30ml per minute. Kidneys are the organs responsible for clearing insulin and other metabolites from the body. Glucose is not excreted from the kidneys in the urine. But if the kidney malfunctions or there is a disturbance with absorption there is glucose excretion in the urine which leads to the detection of diabetes. Glucose is present in urine it is called glucosuria. Albumin, creatinine is the substance when present in urine indicate kidney damage.

Five points to remember for CKD patients:

  • Chronic kidney disease when associated with diabetes it is called as diabetic nephropathy.
  • CKD patients are more likely to develop diabetes in later stages.
  • It is controllable with medications orally, by injections, and by diet.
  • There are a few precautions and contraindications for diabetic control in CKD which are mentioned later.
  • Frequent screening is necessary for these patients with their nephrologist.

Diabetic or sugar management in CKD patients in stages one and two by diet.

Diet is the main reason to stay fit and to deteriorating wellness. Controlling and reshaping the dietary intake is definitely a considerable step to avoid or control diabetic nephropathy.

  • Stop animal products like milk, cheese, chicken, mutton, beef, crabs, etc.
  • Stop the consumption of packaged food items as they contain sugars and salts in saturated forms such as chips, soft drinks, etc.
  • Stop the usage of sugar in the food preparations.
  • Eat at frequent intervals with a lesser quantity.
  • Fruits can be consumed as it contains fructose.
  • Avoid dry fruits like cashew or Kaju, almonds or badam, avocados, figs as they contain a large amount of potassium.
  • Use whole wheat for the diet.
  • Rice can be consumed.
  • Gluten or maida should be avoided in patients with inflammatory bowel diseases. 
  • Leafy vegetables should be cooked and cleaned well by soaking in water to reduce potassium in them.
  • Unsaturated fats should be avoided.
  • Reduced salt intake.
  • Avoid starchy foods like potatoes in the diet.
  • Water intake should be watched properly.
  • Carbohydrates, fats, and proteins should be measured as far as possible in patients with CKD.

Diabetes or sugar management in diabetic nephropathy of stage one, two, three, and four with oral medications

Tablets or medications are used for patients to control sugar levels. These medications for diabetes have various classes in which they are divided into. So, the content of the medications can be:

  • Sulfonylureas: tolbutamide, torazamide, glibenclamide, glipizide, glimepiride, gliclazide.
  • Biguanides: metformin, phenformin.
  • Meglitinides: repaglinide, nateglinide.
  • Thiazolidinediones: troglitazone, rosiglitazone.
  • Amylin medications
  • Dapaglifozin.
  • Sitagliptine

These medications especially sulfonylureas stimulated beta cells of the pancreas to secret insulin. It releases the tension on the kidneys and these medications control diabetes by normalizing glucose levels of the blood.

Uses of these drugs:

  • Maintain blood glucose levels.
  • Controls insulin and glucose balance.
  • Carries out the function of the pancreas.
  • Acid-base balance.

Adverse Effects of these medications:

  • Hypoglycemia.
  • Drowsiness.
  • Loss of consciousness.
  • Light headedness.
  • Sweating and palpitations.
  • Vomiting and nausea.
  • Diarrhea.
  • Convulsions.
  • Allergy.
  • Cardiovascular disturbances.

Drugs to avoid or replace treatment methods by consulting a doctor:

  • Diuretics.
  • Steroids like glucocorticoids and mineralocorticoids.

In severe hypoglycemia:

  • Glucagon is administered.

Other medications:

To reduce cholesterol levels by atorvastatin, HMG CoA reductase.

To control hypertension by furosemide, spironolactone, beta-blockers like propranolol, alfa blockers, diuretics, etc.

Injection or IV preparation to manage diabetes in CKD patients for stages two, three, and four.

Insulin is taken from animals like pigs, cows, and humans too. These are not highly purified and cause allergic reactions. So, synthetic preparations are on the market that does not tend to cause allergic effects on the body.

  • Longer acting insulin is the mixture of insulin along with zinc or protamine.
  • Intermediate-acting insulin is plane protamine.
  • Other insulin preparations are classified into lente, regular, isophane, etc.
  • Insulin analogs are used such as insulin lispro, insulin aspart, insulin detemir, etc.

These preparations are available in the markets and do not require a special skill and can be administered by own self. It can be injected subcutaneously which means under the skin or intravenously.

Depending on the severity of the illness, the dose varies. 2-3 injections can be advised by the doctor.

Management of diabetes in CKD with additional exercise.

The pancreas can get activated by various forms of exercise. This helps along with medications to improve the health and wellbeing of the patient.

  • Walking: walking on a plane surface is a very good option for CKD patients to avoid diabetes. Walking for 20-40 minutes a day can bring about good results.
  • Relaxed pendular movements of limbs: moving the limbs with support and gravity assistance can prove to be relaxing and will keep your muscles intact and in better shape.
  • Deep breathing: it allows the respiratory system to be clean and no secondary complications can occur.
  • Stretching exercises: side bending, forward and backward bending.
  • Avoid overly straining yourself.
  • Small weights: use of weights to build up endurance and strength. One can use a filled one-litre bottle as a weight to lift.
  • Hip movements with knee movements.
  • Shoulder movements and avoiding overhead activities to reduce the load on the heart.
  • Swimming.
  • Sports like badminton, football, basketball can be a good options.
  • Yoga asanas and pranayama are great treatment options too.

Relaxation techniques as a management method to control diabetes in kidney disease.

  • Reducing work load and stress of daily living.
  • Frequently contacting the councilors in case required.
  • Maintain a calm and quiet environment.
  • Music therapy.
  • Building up a Hobbie for a change.
  • Mitchell relaxation techniques.
  • Jacobson relaxation techniques.
  • Pillow placement bellow knee, side lying positions.
  • Yoga.

Environmental modifications and lifestyle changes for the management of high sugar levels in CKD.

  • Stop drinking alcohol.
  • Stop smoking cigarettes.
  • Stop chewing tobacco, gutka, and suparies.
  • Stop cocaine, tranquilizers as abusive drugs.
  • Reduce stress.
  • Maintain healthy relationships.
  • Stay away from the non- vegetarian diet.
  • Reduce weight.
  • Have healthy food and be on time.
  • Full sleep on time.
  • Do not stay up for late hours.
  • Medications should not be missed.

Energy conservation techniques in patients with CKD and diabetes in old age or with other severe complications.

These are the techniques that reduce the energy that the patient has to spend on a normal daily work routine. It includes:

  • Use of reach outs to get things.
  • Use of cane for walking.
  • Not moving or turning abruptly.
  • Accepting help from other family members.
  • Setting reminders for medication.
  • Sitting with doing work.

 How to manage the health of young individuals with CKD and diabetic nephropathy?

  • Rigorous exercise practices like running, squats, planks, swimming, etc by consulting a physiotherapist.
  • Stress reduction.
  • Healthy eating.
  • Emotional support.
  • Management with lifestyle modification without tablets as far as possible.

Social support for diabetic nephropathy.

Social withdrawal can be a common complaint with such patients. To bring them back to normal social life and status a few interventions are required such as:

  • Group exercise programs which include 5-6 patients having the same issue. This can help improve communication and better results can be received.
  • Motivation to the patient by therapist, doctors, and family members.
  • Home exercise programs include leisure scheduling of physical activity for CKD patients.
  • Happy environment.

In uncontrolled cases, the management for diabetic nephropathy.

  • Dialysis: artificial purification of blood by a machine called a dialysis unit. It is costly and draining for the patient. It has a lot of complications and is not preferable for a lifelong kidney failure case where the patient is young or middle aged.
  • Kidney transplant: removing a kidney and replacing it with a donor’s kidney. The match should be very good between donor and recipient. There can be graft versus host reaction or type 4 hypersensitivity. It is a major operation.
  • Nephrectomy: removal of a kidney that is not functioning. This puts stress on the other only kidney. Hypertrophy and hyperplasia of the remaining kidney happen.

Proper assessment of CKD and diabetic patients.

  • Urine test: check for albuminuria, glycosuria.
  • Blood test: Hba1c, random glucose, fasting, and postprandial glucose.
  • Glomerular filtration rate checking.
  • Effect of medication on the patient.
  • Renal function tests.
  • Proper history taking.
  • Checking for blood pressure.

What can happen if diabetic nephropathy is left untreated?

  • Heart failure.
  • Lung complications.
  • Acidosis.
  • Poor wound healing as excessive glucose delays the healing process.
  • Glaucoma, cataract, retinopathy in the eyes.
  • Acid base imbalance.
  • Ketoacidosis and sever complications.
  • Brain damage.
  • Edema or lymphedema.
  • Severe social withdrawal which may lead to depression.
  • Ill effects of the medications.
  • Bedsores in bed ridden patients.
  • Lack of interest.
  • It may lead to coma and uncertain circumstances.