William Vega-Ocasio MD. Internal Medicine - Nephrology Centro Renal Hospital Menonita Cayey 787-535-1001 Ext.
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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