Triple Threat
For people with Type 2 diabetes and heart disease, kidney disease is often a problem, too.
By Rachel Hedstrom
Trifectas can seem fun: hat tricks in hockey, the Triple Crown in horse racing or talented people who can sing, dance and act — like J. Lo, a well-known “triple threat.” But for people living with heart disease, a “triple threat” can mean something very different. That’s because heart disease shares a connection with Type 2 diabetes and chronic kidney disease. Fortunately, there is help and hope for those who live with this trio of medical conditions.
Connecting the Dots
Here is another factor of three to consider: If you have Type 2 diabetes and kidney disease, your risk of dying from a cardiovascular event, like a heart attack or stroke, triples.
Our kidneys are powerful filters that remove toxins from the blood through a complex network of arteries, veins and vessels — all of which are part of our cardiovascular system. Type 2 diabetes puts a lot of stress on all of these structures, both in your heart and kidneys. To stay healthy, it’s vital to keep tabs on both.
“The kidney and the heart should be viewed as a married couple, so if one spouse isn’t doing well, the other will try and help but will not optimally function as well,” explains George Bakris, M.D., professor of medicine and director of the American Heart Association Comprehensive Hypertension Center at UChicago Medicine.
“The kidneys carry out many functions in our body, and these functions all support heart function.” That includes providing a hormone that stimulates production of red blood cells and maintains salt, water and potassium; balancing the acid base; and regulating blood pressure.
The interconnection between the conditions is apparent, adds William Lombard, M.D., a retired nephrologist in Bellingham, Washington, who has, for decades, treated patients with these life-threatening conditions. “There’s no question that kidney disease associated with heavy amounts of protein excretion accelerates vascular disease,” he says.
The American Heart Association’s Know Diabetes by Heart program is helping to educate patients about the triple threat of heart disease, Type 2 diabetes and kidney disease. Research shows a clear link between the three:
- Approximately one-third of people with diabetes develop kidney disease.
- Diabetes can damage blood vessels in your kidneys, which can eventually lead to chronic kidney disease.
- High blood pressure can worsen kidney damage and various cardiovascular risks, like heart attack and stroke.
Dr. Lombard says he cannot emphasize enough the gravity of having this trio of conditions: “It’s the worst of all of them,” he says.
“People with one, and not all three, do OK. But when you add them together, people really do get significant problems, such as higher hospitalization rates and high mortalities because of the combination.”
Risk Factors and Early Warning Signs
If you have heart disease and you add having diabetes and being over age 65 to that, you’re immediately at risk for chronic kidney disease, even if you don’t have it right now.
“The big problem is that neither kidney disease nor hypertension has any distinctive symptoms,” Dr. Bakris says. The Centers for Disease Control and Prevention (CDC) estimates that approximately 15% of U.S. adults — that’s 37 million people — have chronic kidney disease. However, only one in 10 knows that they have this condition.
Chronic kidney disease is slightly more common in women than men and is more common in Black adults than in non-Hispanic white or Asian adults. About 14% of Hispanic adults have chronic kidney disease. Other risk factors include heart disease, obesity, a family history of chronic kidney disease, inherited kidney disorders, past damage to the kidneys and older age.
But the leading causes of chronic kidney disease in adults are diabetes and high blood pressure.
The unfortunate reality is that kidney disease can often be missed until it gets to the point where dialysis is needed. “In our local kidney center,” Dr. Lombard says, “we would see 35% to 50% of people start dialysis who had never even seen a kidney specialist before.” It’s a silent epidemic, he said, mentioning that Type 2 diabetes is also a condition that is easily missed: “Many people who have blood sugars in the range of 150-200 mg/dL have no idea they even have diabetes.”
Another risk factor for chronic kidney disease that has been added to the list in the last year is having had a severe case of COVID-19. “People recovering from COVID-19 who have had kidney injury during the illness are developing progressive injury later,” Dr. Lombard says. “If you have those risk factors, you need to be followed regularly.” A urine test at least every six months is beneficial for patients with risk factors like COVID-19 and others.
While knowing your risk factors is the best way to catch kidney disease and diabetes early, other signs may include ankle swelling, any change in urinary patterns (such as getting up for many more trips to the bathroom than you might have taken before) and excess “foam” in the urine, which is caused by protein. Any of these symptoms warrant a conversation with your primary care physician or cardiologist.
Prevention and Annual Screenings
Fortunately, there are steps you can take keep your heart and kidneys healthy. If you have Type 2 diabetes, talk to your doctor about your annual kidney screening. A simple urine test can identify early signs of chronic kidney disease and give you and your healthcare team necessary information to manage your risk. Dr. Bakris also recommends monitoring your blood pressure daily with a validated home blood-pressure monitor.
“If your blood pressure when you wake up in the morning is greater than 130/80 mmHg, you should let your doctor know,” he said. “If you haven’t had blood chemistries to assess blood sugar and a urine test for kidney function, you should obtain them.”
The American Heart Association and American Diabetes Association have also teamed up to bring science-backed tips, tools and resources for people living with Type 2 diabetes and expert advice on managing risks. They recommend several ways that people living with diabetes can help get ahead of chronic kidney disease:
- At your next appointment, ask your doctor if your diabetes is affecting your kidney function.
- Keep your blood glucose, cholesterol and blood pressure in target ranges.
- Eat a healthy, balanced diet.
- Keep your body moving with daily exercise; shoot for 150 active minutes per week.
- Take your medications as prescribed and talk to your doctor if any side effects occur.
- Get your specialists (cardiologist, endocrinologist, etc.) on the same page.
- Stay positive! Scientists make exciting new discoveries every day that will lead to a brighter future for patients with diabetes and/or heart disease.
“My No. 1 thing is always being positive. So much of recovery is mental,” says Arron Yaras, a member of Mended Hearts® in Salinas, California. Yaras has Type 2 diabetes, kidney failure and heart problems, and has successfully battled cancer twice.
For anyone living with heart disease, diabetes and kidney disease, he recommends adjusting the way you think. “Take the diabetes, for example: I like going on cruises, and when we go there, food is always a major factor. I adjust where I don’t eat bread or starches because I like dessert!”
The 74-year-old retiree focuses on diet and nutrition (a diabetes-friendly diet is also great for heart disease) and visits the gym regularly. “The basic thing is that you’re alive. You have a life,” he says. “Go enjoy it! You can’t let it get to you; you have to keep going. Obviously, you have to watch it — otherwise, it’s going to defeat you — but a positive mental attitude is very important.”
Treatment and Lifestyle
Receiving care for each of the three conditions and maintaining a lifestyle that benefits them is key to survival.
“The things that we know delay the progression of chronic kidney disease are blood pressure control,” Dr. Lombard says, describing a systolic blood pressure number under 120 as the target, based on new research. “And, if patients have diabetes, maintaining good glycemic control is also important.”
The interdependent relationship between each of the three diseases makes the combination of them an even bigger problem if left untreated. For example, people with chronic kidney disease may produce a higher level of protein excretion in their urine. That can cause astronomical cholesterol levels of 350 mg/dL, 400 mg/dL — or more.
Options for treatment include a new class of medications called sodium glucose co-transporter 2 (SGLT2) inhibitors that can lower blood sugar by causing
the kidneys to get rid of more glucose in the urine. “This class of drugs has been shown to prevent progression of heart failure and kidney diseases in those with diabetes,” Dr. Lombard says. “They are revolutionary; a game-changer for people with all three conditions.”
Dr. Lombard stresses that medications are just one piece of the puzzle for people facing the combination of heart disease, diabetes and chronic kidney disease. Quitting smoking is important, as smoking has been shown to accelerate the progression of kidney disease. Maintaining a healthy body mass index (BMI) is also very important.
Because chronic kidney disease is, by nature, progressive, there is no cure. Scarred kidneys progressively damage themselves over time, so treatment and management of all three conditions are vital to extending the life of the organ. Also, if a kidney transplant is being considered, the patient’s heart has to be healthy enough to qualify for the transplant. Yet again, one influences the other.
“I can’t overemphasize the need to stay on all your medications and take them as prescribed,” Dr. Bakris says. “Second, maintain the lifestyle that was prescribed by your physician, dietitian and other professionals. The patients I have that are ‘obsessive-compulsive’ about these factors have done very well — much better than those who do not.”
Seeing his doctors regularly is another thing Yaras does to keep himself as healthy as possible. “You have to find good doctors and have confidence in them,” he says. “The general practitioner I have now was the one who caught my diabetes.”
He also recommends keeping a close tab on how your body feels. In the 30-plus years Yaras has managed the trio of heart disease, diabetes and chronic kidney failure in his own body, he has been deliberate in taking note of when he feels different or “off,” and he communicates that to his doctor so his medications can be adjusted accordingly.
And while his kidneys, pancreas and heart may not function at 100%, it’s another organ that he is convinced is worth focusing the most on: his brain.
“I’m a positive person who tries to look at the bright side,” he said. “I think to myself: How can I readjust and continue living rather than just sitting in a chair and saying, ‘Poor me!’”
