More than 800,000 people in the U.S. are living with end-stage kidney disease, half of whom have diabetes. About 70% receive dialysis, while the rest have undergone a transplant, according to the U.S. National Institutes of Health.
What’s tricky about chronic kidney disease (CKD) is that it frequently goes unnoticed – as many as 90% of those with CKD don’t know they have it. The good news is that kidney disease can often be prevented or slowed through education, regular screening, and proper treatment.
“It’s key to have an early diagnosis of this to prevent worsening kidney function,” said Dr. Juan Salcedo-Betancourt, a nephrologist and assistant professor of clinical medicine at the University of Pennsylvania.
The University of Pennsylvania’s Perelman Center is in the midst of building a multidisciplinary diabetes-related kidney disease clinic in collaboration with endocrinologists, nephrologists, dietitians, and pharmacists.
“We want to focus on early detection of kidney disease, and provide evidence-based and guideline-directed medical therapy to prevent the progression of kidney disease in patients with diabetes,” Salcedo-Betancourt said.
When is dialysis needed?
Dialysis becomes necessary when the kidneys can no longer perform their normal functions and a person needs an artificial way to filter waste, excess fluid, and toxins from the blood – work that healthy kidneys would typically handle, explained Dr. Pranav Garimella, chief medical officer of the American Kidney Fund.
End-stage kidney disease is irreversible and means a person will need dialysis for the rest of their life.
“Unfortunately, early changes in kidney function often don’t cause any symptoms, which is the main reason many patients are unaware they have kidney disease,” Garimella said.
People with diabetes should be aware of the following symptoms, which may signal worsening kidney function and potential kidney failure:
- High blood pressure
- Swelling of the legs and ankles
- Loss of appetite
- Decreased need for insulin or diabetes medicine
- Feeling sick to the stomach or vomiting
- Itchy skin
To measure kidney function, doctors use two tests to determine how well the kidneys are working: a blood test and a urine test.
- The blood test checks a person’s estimated glomerular filtration rate (eGFR) or the amount of creatinine, a waste product, in the blood.
- The urine test measures the urine albumin-to-creatinine ratio (uACR) and checks for a condition called albuminuria, which indicates kidney damage.
How to prevent dialysis
The most effective ways for people with diabetes to delay or avoid dialysis are to treat it early, keep blood glucose and blood pressure well managed, avoid smoking, and use medications that help protect the kidneys from long-term damage, said Barbara Eichorst, a nurse and diabetes educator who serves as the American Diabetes Association’s vice president of healthcare programs.
“For people with diabetes, preventing kidney disease or slowing its progression begins the moment the diagnosis is made,” she said. “When these strategies are started early and applied consistently, they can significantly delay kidney decline and reduce the likelihood of ever needing dialysis.”
Medications
Over time, high blood sugar from diabetes can damage blood vessels in the kidneys, making it harder to filter out waste from the blood. If left untreated, this can eventually lead to chronic kidney disease.
Some diabetes medications offer kidney protection that goes beyond simply lowering blood sugar. “They are now considered essential treatment for many patients with type 2 diabetes and kidney disease,” Garimella added.
- SGLT-2 inhibitors: These cause the kidneys to excrete excess glucose in the urine to reduce pressure inside the kidney's filtering units, which slows scarring and preserves kidney function.
- GLP-1 receptor agonists: Glucose-lowering medications like Ozempic are also approved for slowing the progression of kidney disease.
Additionally, a few non-glucose-lowering kidney protection drugs can be helpful and are vital in diabetes care due to their powerful kidney benefits, Garimella said. These include:
- ACE inhibitors and ARBs: Considered first-line therapy for kidney protection, these medications lower blood pressure and reduce pressure on the kidney filters (e.g., lisinopril, losartan).
- Non-steroidal mineralocorticoid receptor antagonists (nsMRAs): These block the harmful effects of hormones made in or near the kidneys, specifically targeting inflammation and scarring that contribute to progressive kidney disease (e.g., finerenone).
People with diabetes should talk to their healthcare provider about the medications they are taking and any potential side effects they may have, Garimella added.
Eat balanced meals
Nutrition plays a central role in preserving kidney function. Eichorst recommended a plant-based or Mediterranean-style diet, which emphasizes vegetables, fruits, whole grains, beans, nuts, and healthy fats to support healthier blood glucose, lower blood pressure, and reduce inflammation – all of which are critical for kidney protection.
“Many individuals benefit from reducing sodium to help manage blood pressure and choosing moderate, not excessive, amounts of protein to reduce stress on the kidneys,” Eichorst said. “As kidney disease progresses, some people may also need to tailor their intake of potassium or phosphorus with the help of a skilled dietitian.”
Kidney and diabetes-friendly eating can coexist when the focus is on balanced meals, appropriate portions, and collaborative nutritional guidance, she added. Dietary recommendations will vary depending on the stage of kidney disease and lab values.
“Achieving a balanced kidney and diabetes friendly diet can be challenging, and we frequently need assistance from our dietitians to achieve this goal,” agreed Salcedo-Betancourt.
He advised a Mediterranean or DASH diet, which are both rich in fruits, vegetables, whole grains, and lean protein, to help manage blood sugar levels and prevent high blood pressure. Healthy kidney nutrition guidelines are also available from the National Kidney Foundation and the American Kidney Foundation’s Kidney Kitchen.
Get regular exercise
“Regular physical activity is a highly effective yet often underappreciated way to support kidney health in people with diabetes,” Eichorst said. “Movement improves insulin sensitivity, stabilizes blood glucose, lowers blood pressure, and reduces inflammation – four major contributors to kidney damage.”
The ADA recommends at least 150 minutes per week of moderate-intensity aerobic activity, such as walking, swimming, or cycling, combined with strength training twice weekly to maintain muscle mass.
“For individuals with more advanced kidney disease, low-impact activities are better and can be safely adapted to their energy levels and cardiovascular health,” Eichorst said. “The key message is that consistent, moderate movement far more than intense workouts is what provides lasting protection for both metabolic health and kidney function.”
Get regular check-ups
People with type 2 diabetes should start annual kidney disease screening at the time of diagnosis. Those with type 1 diabetes should begin annual screening five years after their diagnosis, Salcedo-Betancourt advised. In addition:
- A1C should be checked at least every six months (every three months if uncontrolled),
- Blood pressure should be checked at every clinic visit,
- uACR and eGFR should be checked at least once a year (every 3-6 months if abnormal)
- A retina and comprehensive foot evaluation should be done at least once a year.
The bottom line
While diabetes is the most common cause of kidney failure that may lead to dialysis, individuals have powerful tools to change that trajectory. Taking steps to safeguard kidney health can meaningfully delay or even prevent the need for dialysis, said Garimella. These include:
- Blood sugar: Keep your A1C level at the goal set by your doctor (usually around 7% or lower).
- Blood pressure: Keep your blood pressure below 130/80 mmHg (or your doctor's target).
- Eat well: Meet with a dietitian to create a healthy eating plan. Focus on limiting salt, excess carbohydrates, and saturated fats.
- Be active: Get at least 30 minutes of physical activity most days of the week.
- Quit tobacco products: Smoking and tobacco speed up kidney damage, so quitting is essential.
- Take all medicines: Consistently take all medicines as prescribed by your doctor.
