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Diabetes and Chronic Kidney Disease Basics: Part One

Published:March 17, 2019DOI:https://doi.org/10.1053/j.jrn.2019.01.014

      Intended Audience: CKD Diabetes Patients, Renal Dietitians

      An estimated 14.8% of adults have chronic kidney disease (CKD).
      United States Renal Data System
      USRDS Annual Data Report. Introduction to Volume 1: CKD in the United States.
      Diabetic kidney disease (DKD) is classified according to the presence of microalbuminuria or macroalbuminuria.
      National Kidney Foundation
      KDOQI clinical practice guideline for diabetes and CKD: 2012 update.
      Of the 30 million United States (US) individuals with diabetes, those who met any criteria for DKD is estimated at 26.2%. Using 2010 census data, this translates to a prevalence of approximately 8.2 million people with any DKD, including 4.6 million people with albuminuria, 1.9 million people with macroalbuminuria, 4.5 million people with reduced estimated glomerular filtration rate (eGFR), and 0.9 million people with severely reduced eGFR.
      • Afkarian M.
      • Zelnick L.R.
      • Hall Y.N.
      • et al.
      Clinical manifestations of kidney disease among US adults with diabetes, 1988-2014.
      DKD typically develops after a diabetes duration of 10 years in type 1 diabetes but may be present at diagnosis in type 2 diabetes. DKD can progress to end-stage renal disease requiring dialysis or kidney transplantation and is the leading cause of renal failure in the US. In addition, among patients with type 1 or type 2 diabetes, the presence of CKD markedly increases cardiovascular risk.
      American Diabetes Association
      10. Microvascular complications and foot care: standards of medical care in diabetes – 2018.
      The primary nutrition recommendations for diabetes include an individualized meal pattern, but to maintain stable blood glucose levels, it is important to focus on the amount of carbohydrate at meals. Carbohydrate intake from vegetables, fruits, legumes, whole grains, and dairy products, with an emphasis on foods higher in fiber, is preferred over other sources, especially those containing added sugars. For individuals with type 1 diabetes and those with type 2 diabetes who are prescribed a flexible insulin therapy program, education on carbohydrate counting and, in some cases, fat and protein gram estimation to determine mealtime insulin dosing is recommended to improve glycemic control. For diabetics whose daily insulin dosing is fixed, a consistent pattern of carbohydrate intake with respect to time and portions may be recommended to improve glycemic control and reduce the risk of hypoglycemia.
      American Diabetes Association
      10. Microvascular complications and foot care: standards of medical care in diabetes – 2018.
      Appropriate nutrition interventions may have an effect on clinical outcomes in the DKD population.
      • Tuttle K.R.
      • Bakris G.L.
      • Bilous R.W.
      • et al.
      Diabetes kidney disease: a report from an ADA consensus conference.
      The optimal meal plan for DKD varies depending on eGFR or stage of kidney disease and the presence of additional comorbidities such as hypertension or heart failure. Although meal planning for diabetes requires changes to an individual's daily life, the addition of adjustments for CKD adds an extra level of complexity and confusion. Teaching the person with DKD requires extensive ongoing education regarding the effect of carbohydrate on blood glucose levels along with dietary adjustments of protein, potassium, phosphorus, and sodium. It is beyond the scope of this article to compile an extensive handout for DKD, but rather to focus on carbohydrate-containing foods with key nutrients that should be limited with DKD.
      This is the first of a 2-part series covering basic information for individuals with DKD. This first handout is not meant to replace the registered dietitian nutritionist who specializes in renal nutrition but rather provides a starting point to be used by the nonspecialist with the individual with DKD to focus on phosphorus, potassium, and carbohydrate sources. Given that protein and sodium content is readily available on nutrition facts labels, this handout will cover items that are not as easily identified by individuals and health care professionals. The second part of this series provides an overview of DKD nutrition recommendations, along with a 7-day sample menu to be used with individuals.

      References

        • United States Renal Data System
        USRDS Annual Data Report. Introduction to Volume 1: CKD in the United States.
        Am J Kidney Dis. 2017; 69: S1-S32
        • National Kidney Foundation
        KDOQI clinical practice guideline for diabetes and CKD: 2012 update.
        Am J Kidney Dis. 2012; 60: 850-886
        • Afkarian M.
        • Zelnick L.R.
        • Hall Y.N.
        • et al.
        Clinical manifestations of kidney disease among US adults with diabetes, 1988-2014.
        JAMA. 2016; 316: 602-610
        • American Diabetes Association
        10. Microvascular complications and foot care: standards of medical care in diabetes – 2018.
        Diabetes Care. 2018; 41: S105-S118
        • Tuttle K.R.
        • Bakris G.L.
        • Bilous R.W.
        • et al.
        Diabetes kidney disease: a report from an ADA consensus conference.
        Diabetes Care. 2014; 37: 2864-2883