Transcript دكتر شهيدي۱

DM & CKD
Dr. Shahrzad Shahidi
Professor of Nephrology
Isfahan University of
Medical Sciences
CKD

3
Kidney damage for ≥ 3 months, defined by
structural or functional abnormalities of the kidney, ±
decreased GFR, manifest by either:
 Albuminuria (AER ≥ 30 mg/24 hs; ACR ≥ 30 mg/g Cr)
 Urine sediment abnormalities
 Electrolyte & other abnormalities due to tubular
disorders
 Abnormalities detected by histology
 Structural abnormalities detected by imaging
 Hx of kidney transplantation

GFR < 60 mL/min/1.73 m2 for ≥ 3 months ± kidney damage
4
If no other markers of
kidney disease, no
CKD
Moderately increased
risk
Very high risk
High risk
Diabetic Nephropathy
 Over 40% of new cases of
end-stage renal disease
(ESRD) are attributed to
diabetes.
The 5-year mortality rate for
a dialysis patient with
diabetic nephropathy is
93%.
Dialysis for one patient costs
over $50,000 annually.
Incidence of ESRD
Resulting from Primary
Diseases (1998)
19%
3%
43%
12%
23%
Diabetes
Hypertension
Glomerulonephritis
Cystic Kidney
Other Causes
Diabetic Nephropathy
 DN
occurs in 35-40% of patients with type
I diabetes (IDDM) whereas it occurs only
in 15-20% of patients with type II diabetes
(NIDDM).
 Definition
 Presence
or Criteria for diagnosis of DN
of persistent proteinuria in sterile
urine of diabetic patients with concomitant
diabetic retinopathy & HTN.
GFR
Stages of
Diabetic Nephropathy
180
160
140
120
100
80
60
40
20
0
II
III
I
IV
V
0
5
10
15
20
Duration of Diabetes
25
30
Nephropathy Risk Factors
 DM
Type & Duration
 Poor diabetic control
 HTN
 Race (Aboriginal > Indian > Caucasian)
 Smokers
 Family history
Nephropathy Risk Factors
Modifiable
 HbA1c,
BP & total cholesterol
 Obesity, smoking
Non-modifiable
 Age,
ethnicity
Screening for Diabetic Nephropathy
Test
When
Normal Range
Blood
Pressure1
Each office visit
<130/80 mm/Hg
Urinary
Albumin1
Type 2: Annually
beginning at diagnosis
Type 1: Annually, 5-years
post-diagnosis
<30 mg/day
<20 g/min
<30 g/mgcreatinin
1ADA
Diabetes Care 27
Screening
Measurements
of urinary ACR in a
spot urine sample.
Measurement of serum Cr &
estimation of GFR.
How are we doing?
Studies show that primary
care physicians screen only
20% of their diabetic
patients for diabetic
nephropathy
Microalbuminuria
 Spot
AM urine: Alb/Cr ratio 30-300 mg/g Cr*
 Timed urine collection: 20-200µg
albumin/min
 24 hour urine collection: 30-300 mg
albumin in 24 hours
*This is the most practical test
Incipient Nephropathy
IDDM
2
out of 3 urine tests + for
microalbuminuria
 Presence of proliferative diabetic
retinopathy
 80-90% of type 1 patients with
microalbuminuria will progress to DN
Incipient Nephropathy
NIDDM
 2 out of 3 urine tests + for
microalbuminuria (start screening at the
time of diagnosis of DM)
 Presence of diabetic retinopathy
 20-30% may have diabetic nephropathy
but not diabetic retinopathy
 25% may have a diagnosis of nephropathy
other than diabetic nephropathy
Q. Which features are typical of
diabetic CKD at presentation ?
Haematuria
No
Small scarred kidneys
No
Progress to ESKD in <2yrs
No
Associated retinopathy
Yes
β-blockers better than ACE-I Rx No
Other cause(s) of CKD should be
considered in the presence of any
of the following circumstances:
 Absence
of diabetic retinopathy
 Low or rapidly decreasing GFR
 Rapidly increasing Pruria or nephrotic syndrome
 Refractory HTN
 Presence of active urinary sediment
 Signs or symptoms of other systemic disease
 >30% reduction in GFR within 2-3 ms after
initiation of an ACE I or ARB.
Treatment of Diabetic Nephropathy (cont.)
Glycemic
Control
 Preprandial
plasma glucose 90-130 mg/dl
 A1C
~ 7.0%
 Peak postprandial plasma glucose <180 mg/dl
 Self-monitoring of blood glucose (SMBG)
 Medical Nutrition Therapy
Target
dietary Pr intake for people with
DM & CKD stages 1-4 should be the RDA
of 0.8 g/kg/d.
Management of Hyperglycemia
& General Diabetes Care in CKD
 Target
HbA1c of ~ 7.0% to prevent or delay
progression of the microvascular
complications of DM, including DKD.
 Not treating to an HbA1c target of <7.0% in
patients at risk of hypoglycemia.
 Target HbA1c be extended above 7.0% in
individuals with co-morbidities or limited
life expectancy and risk of hypoglycemia.
Metformin in CKD
 No
hypoglucemia or weight gain
 Inexpensive
 BUT:
 Renally-excreted
 Excess
doses → anorexia, diarrhea
 Dose adjust to GFR: 2g to 250mg/day
 Protocol says
 eGFR
30 – 45 max 1gm/day
 Cease when eGFR <30 but…
 Risk
of fatal lactic acidosis if unwell
Management of Dyslipidemia
in Diabetes & CKD
 Using
LDL-C lowering medicines, such as
statins or statin/ezetimibe combination, to
reduce risk of major atherosclerotic
events in patients with diabetes & CKD,
including those who have received a
kidney transplant.
 Not initiating statin therapy in patients
with diabetes who are treated by dialysis
Management of Albuminuria in
Normotensive Patients with Diabetes
 Not
using an ACE-I or an ARB for the
primary prevention of DKD in normotensive
normoalbuminuric patients with diabetes.
 Using an ACE-I or an ARB in normotensive
patients with diabetes & albuminuria levels
>30 mg/g Cr who are at high risk of DKD or
its progression.
BP management in
CKD ND patients with DM
 Adults
with DM & CKD ND with urine albumin
excretion < 30 mg/d whose office BP is consistently >
140 mmHg systolic or > 90 mmHg diastolic be treated
with BP lowering drugs to maintain a BP that is
consistently ≤140 mmHg systolic & ≤ 90 mmHg diastolic.
 Adults with DM & CKD ND with urine albumin
excretion > 30 mg/d whose office BP is consistently
>130 mmHg systolic or > 80 mmHg diastolic be treated
with BP lowering drugs to maintain a BP that is
consistently ≤130 mmHg systolic & ≤ 80 mmHg diastolic.
 ARB or ACE-I be used in adults with diabetes & CKD
ND with urine albumin excretion of ≥ 30 mg/d.
Diabetes & ESRD
 Reducing
insulin requirements
 Difficult vascular access
 Accelerated macrovascular disease
 Advanced microvascular disease
 Frequent sepsis
 Silent ischaemia
 2-3 x death rate vs non-DM patients
How can DM effect Dialysis?
 Autonomic
neuropathy – may suffer hypotension
increased by large fluid shift in HD
 Uncontrolled BS – may absorb some glucose in PD
fluid
 Severe PVD – difficult to get vascular access for HD
 PVD may also affect peritoneum & reduce PD
success
 Increased risk of infections – problem in both
 Transplants – new kidneys develop nephropathy,
hence good glycaemic control important
Case #1
 Your
first pient is a 25 y old young
man with a 5 year Hx of type 1 DM.
 His
urine dipstick is negative for Pr.
 Spot AM urine Alb/Cr ratio is 19 mg/g Cr.
 His BP is 112/66 mmHg.
 His HbA1C is 6.9%.
Which is (are) true?
1.
2.
3.
4.
The patient has early or incipient diabetic
nephropathy.
The patient should maintain a HbA1C of
less than 7 to help protect his kidneys.
You should start the patient on an ACE
inhibitor to protect his kidneys.
All of the above are true.
Patient #2

43 y old woman with a 6 year Hx
of type 2 DM.
A
urine dipstich shows trace Pr
 Spot AM urine ACR 390 mg/g Cr
 BP is 135/80
 HbA1C is 6.7%
Which is (are) not true?
1.
2.
3.
4.
You should check the patient’s serum Cr &
K.
You should start the patient on an ACEI if
her K & Cr are okay.
You should check a 24 hour urine for total
Pr & Cr clearance.
The patient has overt diabetic nephropathy
& should be referred to a nephrologist.
Case #3
60
y old man with HTN, dyslipidemia
& newly diagnosed type 2 DM.
A urine dip shows 2+ Pr
He has a fever & his HbA1C is 10.3%
BP is 140/88
He is taking HCTZ & Glipizide

Which is (are) true?
1.
2.
3.
4.
You should get the patient’s
diabetes under better control
before rechecking his urine.
A fever will not cause proteinuria.
The patient’s BP is under good
control.
You should check the patient’s K &
Cr.
Case #3
3
months later with exercise,
metformin & Enalapril your
patient’s HbA1C is now 7.5 & his
BP is 135/85.
A urine dip now shows 1+
protein.
Which is (are) true?
1.
2.
3.
You should check a 24 hour urine for
total Pr & Cr. cl.
A spot AM urine ACR correlates well
with a 24 hour urine for total Pr
The patient likely already has diabetic
nephropathy & should be referred to a
nephrologist.
Use the Algorithm!
Check
all your diabetic patients
annually for renal disease .
Help your diabetic patients’ protect
their kidneys by helping them keep
their diabetes under control.
Help your diabetic patients protect
their kidneys by helping them keep
their BP under control.