Treatment
The earliest sign of kidney disease is finding small amounts of protein in the urine (microalbuminuria). Your urine needs to be checked once a year starting 5 years after the diagnosis of type 1 diabetes, or starting at the diagnosis of type 2 diabetes. This can be done at your provider’s office, or you can do the test at home and mail it in. Make sure your urine is tested for microalbuminuria, not just proteinuria. If you have this early sign of nephropathy, the first step is to bring your blood glucose levels into the target range. In the DCCT, people with microalbuminuria who were in the intensive management group cut their risk of progressing to a more serious stage of kidney disease in half. To reap this benefit, these study participants kept an A1C of 8.1% or lower. You may also be advised to begin a diet low in salt. Blood pressure medications called ACE inhibitors or ARBs are usually prescribed, even if your blood pressure is in the recommended range. ACE inhibitors and ARBs decrease the rate of progression of kidney disease.

If your kidney disease becomes more advanced, more will need to be done. A low-protein diet may be recommended. If the kidneys fail,  they are no longer able to do their job of filtering out toxins from your body. This condition is known as end-stage renal disease. At this point, the only two treatment options are dialysis and kidney transplantation. Both remedies are ways of replacing the kidneys.

Dialysis uses a machine to artificially do the job that the kidneys are no longer able to do. There are different types of dialysis, but they all accomplish the same thing - removing toxins from the blood. One type of dialysis, called hemodialysis, removes the blood from an artery (usually in the arm), filters it through a machine,  and returns it to a vein.  If you need hemodialysis, you will most likely go to a dialysis treatment center three times a week for 2 to 4 hours. Or you may be able to have a trained caregiver come to your home to provide hemodialysis.

The other type of dialysis is called peritoneal dialysis. Here, instead of using a machine to filter the blood, the abdominal cavity, or peritoneum, serves as the filtering site. A solution called a dialysate is poured through a small tube into the abdomen, where it is allowed to sit and collect waste products.

Waste products from the blood are exchanged in the peritoneum. After a few hours, the dialysate, which now contains the wastes, is drained out of the abdomen.

This process can be performed manually by letting gravity carry the dialysate into the cavity and drain it out again. Or, a machine can carry out the exchange, usually overnight.

Transplantation is usually more effective than dialysis. A new kidney functions as well as your old ones did before disease. However, it depends on the availability of a kidney and requires taking drugs that suppress the immune system to prevent rejection of the new kidney. A genetically near-identical donor is desirable, but not essential. A relative may be willing to donate a healthy kidney, or a kidney may become available from someone who has just died. People often go on dialysis while waiting for a transplant. Some people choose to have a pancreas transplant at the same time. Pancreas transplants are always from organ donors who have died.

Transplantation has its risks as well. It is major, expensive surgery and requires good cardiovascular health. The drugs you must take to prevent immune rejection of the new kidney may put you at a greater risk of developing infections. And the new kidney will face the same pressures as the old ones did.

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Martha M. Funnell, MS, RN, CDE
Michigan Diabetes Research and Training Center
University of Michigan Medical School
Ann Arbor, Michigan

Robert M. Anderson, EdD
Michigan Diabetes Research and Training Center
University of Michigan Medical School
Ann Arbor, Michigan

Shereen Arent, JD
National Director of Legal Advocacy
American Diabetes Association

American Diabetes Association Complete Guide to Diabetes