William Vega-Ocasio MD.

Internal Medicine - Nephrology Centro Renal Hospital Menonita Cayey 787-535-1001 Ext. 5503 [email protected]

Diabetic Nephropathy

The Dietitian Intervention

Objectives

 Definition of Diabetic Nephropathy  Prevention and management of Diabetic Nephropathy  Nutritional Management of Diabetics with Advance Renal Disease

Overview

 Diabetes Mellitus  Disorder of impaired carbohydrates metabolism.

 Either Insulin deficiency or Insulin resistant state.

 Characterized by hyperglycemia (inadequate production or utilization of insulin).

 Multi systemic organ damage : eyes, nerves, blood vessels, heart and kidneys.

Overview

 Diabetes Mellitus  Advance glycosylation of tissue proteins (AGEP)  Irreversible glycosylation of Hemoglobin  Microvascular damage ( nephropathy & retinopathy)  Renal and Cardiovascular complications  Direct effect in Lipid metabolism

Diabetic Nephropathy

 Leading cause of and contributor to End Stage Renal Disease “ESRD” (CKD V)  Development is related to duration and degree of hyperglycemia of diabetes  Progresses in stages to CKD V if not treated

Diabetic Nephropathy

 Occurs in both DM Type I & II  Peak incidence of disease for Type I diabetics is between 10 - 15 years after onset of disease  Usually already present for those diagnosed with Type II Diabetes

Diabetic Nephropathy

Microvascular Damage Carbohydrates Load HEART VASCULAR SYSTEM KIDNEY Increased Transforming Growth factor Angiotensin Platelet Derived Growth factor Abnormally Regulated Thromboxanes and Endothelins Insulin Deficiency Hyperglycemia

Diabetic Nephropathy

 Characterized :  Microvacular damage to kidney  Earliest clinical evidence is appearance of microalbuminuria ( incipient nephropathy )  Slowly progressive disorder  Untreated will result in massive protein excretion and decreased glomerular filtration rate ( ↓ GFR)

Untreated Diabetic Nephropathy

Diabetic Nephropathy

Hyperglycemia Nephropathy ESRD

Diabetic Nephropathy

STAGE GFR URINE PROTEIN BP I. Hyperfiltration Super normal <30mg/day Normal II. Micro- Alb High-Normal 30-300mg/day Rising III. Proteinuria Normal-Decreasing <300mg/day Elevated IV. Nephropathy Decreasing Increasing Elevated V. ESRD <15mL/min Massive Elevated

National Kidney Foundation “Primer on Kidney Diseases” Fourth edition Elsevier Saunders

From

EdREN

, the website of the Renal Unit of the Royal Infirmary of Edinburgh

Diabetic Nephropathy Stage I

 Stage I-A  Increased Kidney Filtration    Osmotic load and Toxic effects of hyperglycemia Increased Glomerular Filtration Rate Kidney enlargement  Stage I-B  Silent Phase    Hyperfiltration Hypertrophy Increased production of inflammatory mediators

Diabetic Nephropathy Stage II

 Microalbuminuria (30-300mg/day)  Basement membrane thickening due to AGEP’s  Increased Microvascular damage  Cardiovascular disease and retinopathy  20% risk of

nephropathy

standard care within 5 years with 

Glomerular Filtration Rate

not markedly affected, but kidney inflammatory damage

Diabetic Nephropathy Stage III

 Proteinuria (>300mg/day)  Decreased Glomerular filtration Rate 

Severe protein wasting

with it complications  Up to 10% of patients may excrete

< 3000mg/day

 Systemic microvascular and cardiovascular disease complications  Abnormal lipid metabolism (Cholesterol & Triglycerides)

Diabetic Nephropathy Stage IV

 Prepare for Treatment       Progressive nephropathy Markedly decreased GFR

Signs and Symptoms of Protein Calorie malnutrition

Advance Retinopathy Cardiovascular catastrophes Cerebrovascular catastrophes

Diabetic Nephropathy Stage V

 End Stage Renal Disease (CKD V)  Renal Replacement therapy 

Severe protein calorie malnutrition

 Severe peripherovasclular disease  Cerebrovascular Disease  Cardiovascular Disease  Infections

Objectives

 Definition of Diabetic Nephropathy  Prevention and management of Diabetic Nephropathy  Nutritional Management of Diabetics with advance Renal Disease

Diabetic Nephropathy

Hyperglycemia Progression of Disease Nephropathy Regression of Disease ESRD

National Kidney Foundation

Diabetic Nephropathy

 Stages of CKD  I : Above normal GFR  II : Glomerular Damage, Microalbuminuria (30-300mg/day)  III : Proteinuria (>300mg/day),Hypertension   IV : More Glomerular Damage, Increasing Proteinuria, Decreased GFR → Azotemia V : GFR < 15ml/min/1.73m

2 → Renal Replacement Therapy

From Chronic Kidney Disease, Dialysis, and Transplantation, Second Edition, Elsevier Saunders 2005

From Chronic Kidney Disease, Dialysis, and Transplantation, Second Edition, Elsevier Saunders 2005

Prevention or Regression of Disease

Prevention or Regression of Disease



Glycemic Control



Hypertension Control



Control Microalbuminuria or Proteinuria



Dietary Protein Restriction*



Treatment of Dyslipidemias

Diabetic Nephropathy



Glycemic Control

 Partially reverse glomerular hypertrophy and hyperfiltration  Delay development of microalbuminuria  Delay the onset or progression of nephropathy  Delay onset of microvascular damage to organs

Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

Diabetic Nephropathy



Hypertension Control

 Single most effective measure for delaying progression of Chronic Kidney Disease  Aggressive treatment is able to decrease the rate of Diabetic Nephropathy Progression    Reduce microvascular cardiac, retinal and systemic complications Goal BP Target

≤ 130/85 in diabetics

Goal BP Target

≤ 125/75 in nephropathy

Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

Diabetic Nephropathy



Antihypertensive Agents



Angiotensin converting enzyme inhibitors (ACE)



Angiotensin Receptor Blocker (ARB)

 Calcium Channel Blocker (CCB)    Diuretics ( Loop and Thiazides ) β – Blockers α – Blockers

Diabetic Nephropathy



Control Microalbuminuria or Proteinuria

    Untreated will accelerate the progression of diabetic nephropathy

ACE inhibitors

delay progression of nephropathy in Type I DM

ACE inhibitors and ARB’s

from microalbuminuria to proteinuria In Type II DM delay progression

ARB’s

delay progression to nephropathy in Type II DM with HTN and CKD

Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

Diabetic Nephropathy



Dietary Protein Restriction

     

Careful

Restriction

Not all patients are candidates

Helps by reducing hyperfiltration Helps by reducing intraglomerular pressure Retards progression of renal disease Recommendations 0.6 - 0.8 grams per kilogram of body weight a day

Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

STOP !!!

Diabetic Nephropathy

 Proteinuria :  Loss of Immunoglobulins  Loss of lipoproteins  Loss of tissue regeneration proteins  Protein Calorie Malnutrition

Protein Restriction ?

Diabetic Nephropathy

 …low protein diets may actually harm this population, primarily by aggravating malnutrition….

Diabetic Nephropathy

 …there is suggestive clinical and experimental evidence that dietary protein restriction may be ineffective in CKD patients receiving standard anti-proteinuric therapy with ACE inhibitors or ARB’s .

Diabetic Nephropathy

 …low protein diets are associated with both statistically and clinically significant declines in nutritional markers in CKD populations, in whom the prevalence of malnutrition is 50%.

Diabetic Nephropathy



Treatment of Dyslipidemias

 Important in prevention of atherosclerosis  Reductase inhibitors (Statins) may protect against glomerulosclerosis  ADA Goals for Lipids: • • LDL ≤ 100 mg/dL HDL ≥ 40 mg/dL

Objectives

 Definition of Diabetic Nephropathy  Prevention and management of Diabetic Nephropathy  Nutritional Management of Diabetics with advance Renal Disease

Evidence model for stages in the initiation and progression of chronic kidney disease (CKD) and therapeutic interventions Levey, A. S. et. al. Ann Intern Med 2003;139:137-147

Diabetic Nephropathy

 Management Early stages ( I & II) :        Strict Glycemic control !!!

Potassium Restriction Treatment of dyslipidemias Sodium Restriction Remove Irritants from diet Nutritional Supplements ( FA, Iron, etc..) Family support Plan

Diabetic Nephropathy

 Management Advanced stages ( III & IV) :  Glycemic control,

avoid hypoglycemia

!!!



Potassium Restriction

!!!

 Phosphorus Restriction  Treatment of dyslipidemias  Sodium

Removal

from diet 

Remove Irritants from diet

 Nutritional Supplements ( FA, Iron, etc..)  Prepare for Treatment

Summary



Early referral is essential !!!



Work with your nephrologists or endocrinologist



Identify, treat and prevent malnutrition



Know your patients medications



Join educational efforts

Thank You !!!