Managing diabetic kidney disease

SINGAPORE - For four years, Madam Ang (not her real name) had been making regular visits to the polyclinic for routine blood and urine tests.

During one of her visits in early 2012, not only was her blood sugar level found to be higher than normal, but there were also traces of protein in her urine.

After going through her test results, we found out she had diabetic kidney disease (DKD).

She has a family history of diabetes and her blood sugar level had been on the high side for a couple of years.

The 64-year-old retiree was faced with a grim risk: If she could not keep her blood sugar level in check, she could suffer from kidney failure and, eventually, need dialysis.

Madam Ang's condition is not an isolated case. Managing DKD in such patients is inextricably linked to managing their diabetes properly.

Studies have shown that chronic kidney disease affects more than one in 10 people worldwide.

It places an enormous burden on the patients and caregivers.

According to the Singapore Renal Registry (2009), 61.7 per cent of all patients starting dialysis had DKD.

This is not surprising, given that diabetes is one of the top chronic diseases among Singaporeans aged between 18 and 69, according to the Singapore Burden of Diseases Study in 2010.

DKD develops in individuals with poorly controlled diabetes.

High glucose levels in the blood damage the kidney filters, leading to small quantities of albumin (protein) leaking from the blood into the urine.

With worsening damage from high glucose levels, more albumin leaks into the urine.

The greater the leakage, the more severe the degree of diabetic kidney damage - which also means that DKD becomes less reversible.

Eventually, the damage would cause reduced kidney function and end-stage kidney disease, a condition in which the kidneys are failing and no longer able to function at a level needed for day-to-day living.

At that stage, a patient will either need a kidney transplant or be put on dialysis for life.

That is why, if DKD is not properly managed, it can lead to end-stage kidney disease.

Worrying scenario

Unfortunately, Singapore is noted to have the second-highest incidence of this problem in the world.

In 2012, the Singapore Renal Registry reported that 65.4 per cent of all patients starting dialysis had DKD.

This is indeed a worrying scenario. In a study conducted among diabetic patients at the National Healthcare Group Polyclinics between 2006 and 2009, nearly one in two had DKD.

Complications which can arise from diabetes and its impact on kidney health make for a sobering reality.

Diabetes is a chronic illness which requires continuous medical care and patient self-management education and support to prevent and reduce the risk of long-term complications.

With more people living with the disease, they need to be empowered to take charge of their condition.

Diabetes care is complex. It is necessary to motivate DKD patients such as Madam Ang, who are cared for in the community, to be aware of and to take control of their health.

At the polyclinics, we share with patients the strategies of living with diabetes: control their diabetes and blood pressure, get their cholesterol levels, DKD and heart condition checked, comply with medication and change their lifestyle.

Patients should see their doctors to have their HbA1c levels, a marker for blood glucose control, checked regularly. Blood pressure should also be checked regularly by their doctors to ensure optimal control.

As a high cholesterol level predisposes a diabetic patient to coronary artery disease, patients should see their doctors to have their cholesterol levels checked and monitored.

DKD can be slowed by controlling one's blood pressure and treating albuminuria, or excess protein in the urine, with medication.

It is important for patients with DKD to check with their doctors for suitable medication to reduce albuminuria.

Proper care

Lastly, patients are advised to exercise regularly, control their diet and weight, quit smoking and manage stress by setting aside time to relax.

Through these strategies, Madam Ang was fortunate that her DKD condition was detected early and her urine protein could be reduced with treatment.

She was placed under the Nephrology Evaluation, Management and Optimisation (Nemo) programme, a collaborative project by the Division of Nephrology at the National University Hospital and the polyclinics.

The programme uses information technology and Nemo coordinators to coordinate the care of patients with kidney disease at the polyclinics.

Under the care of the team, Madam Ang dutifully attended all her follow-up consultations and stayed on the medicine prescribed to her.

Being empowered with relevant information about her health, exercising regularly and controlling her diet has helped Madam Ang better manage her condition.

Today, she continues to enjoy walks with her husband and is an active line dancer.

Finding out you have DKD does not spell an end to life as you know it.

With proper care and good control of one's diabetes, living a normal life is easily within reach.

enquiries@nhgp.com.sg

Dr Lim is deputy director of clinical services and family physician, consultant, at the National Healthcare Group Polyclinics.

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