Transcript DIABETIC NEPHROPATHY - Dr Arpan Bhattacharyya

Diabetes and Kidney
Normal Kidney
Diabetic Kidney
Diabetic nephropathy
Commonest cause of Renal failure
50 % of dialysis patients have DM
30 % of patients with type 1 & 2
develop renal failure
This number will increase as the diabetic population is
increasing
Risk factors for developing Diabetic
Nephropathy
Poor control of blood glucose,
Long duration of Diabetes,
Presence of other diabetic complication,
Ethnicity (Asian, Pima Indians),
Pre-existing High BP,
Family h/o of Diabetic Nephropathy,
Family h/o Hypertension.
Diabetic Nephropathy
Clinical syndrome consisting of
– Protein in urine
– High BP
– Decline in renal function
If > 25 years elapse - unlikely to develop
nephropathy.
Proteinuria
Protein (mg)
Albumin (mg)
Normal
30-150
10-30
Micro
<500
<300
Macro
>500
>300
Nephrotic range >3000
No need to
check
Microalbuminuria
Called micro… because it is not detectable by
normal urine dip stick
Urinary albumin (30 - 300 mg/day)
Becomes irreversible when reaches 300
Detected by newer generation dipstix (micral)
Screening for microalbuminuria
Whom to screen
– Type 1 DM, from 5 years from diagnosis,
– Annually from diagnosis
Abnormal tests
– Exclude recent vigourous exercise, fever, heart
failure, urine infection, Prostatitis and menstruation,
– Confirm observation twice,
– Look for hypertension
Strict glycemic control prevents
microalbuminuria in type 1
30
25
Percent of patients
Conventional
Intensive
20
15
10
5
0
0
1
2
3
4
5
Year
6
7
8
9
Hypertension
BP of < 130 / 80 is ideal
– Prevents progression of Renal Failure
–  myocardial hypertrophy
ACE I / ARBs
-
drugs of choice
Use with caution if S.Creatinine > 3 mg
Choice depends on comorbid conditions
too
 b blocker in CAD
Diet
Calories - 35 K cal / kg
Proteins of high quality - 0.8 gm / kg
Salt - 4 - 5 gm / day
Potassium - 50 - 60 meq/day
Lipids 30 % of calorie intake.
Fluid management
Many diabetics have nephrotic state and severe
edema and need rigorous salt & fluid restriction
Severe edema
- 600 - 800 ml / day
Mild to moderate
- equal to UOP
No edema
- UOP + insensible
losses
Ca - PO4 metabolism
To be tackled early to prevent secondary
hyperparathyroidism
AIM
– Ca ~ 10, PO4 < 5.5 , Ca X PO4 < 55
– Ca supplementation 1 - 1.5 gm / day
CaCO3 - 40 % elemental Ca
Ca acetate 20 %
Ca with meals will act as PO4 binder
To be given empty stomach for Ca suppl.
– Vit D3 0.25 – 1 mg /day
If PO4 very high, to be reduced first
Anaemia
May occur when GFR < 50 % & almost always
present when GFR < 30 %
Correct deficiencies
– Iron, Folic acid, Vit B12, Pyridoxine
Erythropoietin 75 - 150 iu/kg SC
– With Iron supplements
– Expensive therapy Rs. 8 - 10, 000 / month
– Hb % maintained at 11 - 12
> 13 in pts with CAD
Others
Lipid lowering - diet, statins
Low dose aspirin
Avoid nephrotoxic drugs & contrast procedures
Prevent & treat infections energetically
Hepatitis B immunization
– Early immunization ideal
– if Cr. > 3 double & more frequent dosing
Options of Renal Replacement
Therapies
Dialysis
– Hemodialysis
– Peritoneal dialysis
Continuous Ambulatory Peritoneal Dialysis
Continuous Cyclic Peritoneal Dialysis
Renal Transplantation
Simultaneous Pancreas Kidney
Transplantation
Renal replacement therapy
Very expensive
Hemodialysis (HD)
- Rs. 12 - 15000 / mo
Peritoneal dialysis (PD) - Rs. 20000 / mo
Renal Transplantation - 3 - 3.5 Lakhs for
first year
Not funded by the Government
Not covered by insurance
Hence the real need to prevent diabetic ESRD
Conclusion
Pathogenesis and progression of Renal
Disease in Diabetics is multifactorial and
intervention should be multi-pronged
Glycemic control
Hypertension control
Treat dyslipdemia
Others
– Diet, Smoking cessation, Exercise etc.