Diabetic NephropathyDiabetic Nephropathy

Diabetic NephropathyDiabetic Nephropathy Over 40% of new cases of end-stage

renal disease (ESRD) are attributed to diabetes.

In 2001, 41,312 people with diabetes began treatment for end-stage renal disease.

In 2001, it cost $22.8 billion in public and private funds to treat patients with kidney failure.

Minorities experience higher than average rates of nephropathy and kidney disease

Incidence of ESRD Resulting from Primary

Diseases (1998)

43%

23%

12%

3%

19%

Diabetes

Hypertension

Glomerulonephritis

Cystic Kidney

Other Causes

Five Stages of Kidney DiseaseFive Stages of Kidney Disease

Stage 1: Hyperfiltration, or an increase in glomerular filtration rate (GFR) occurs. Kidneys increase in size.

Stage 2: Glomeruli begin to show damage and microalbuminurea occurs.

Stage 3: Albumin excretion rate (AER) exceeds 200 micrograms/minute, and blood levels of creatinine and urea-nitrogen rise. Blood pressure may rise during this stage.

Five Stages of Kidney Disease (con’t.)

Five Stages of Kidney Disease (con’t.)

Stage 4: GFR decreases to less than 75 ml/min, large amounts of protein pass into the urine, and high blood pressure almost always occurs. Levels of creatinine and urea-nitrogen in the blood rise further.

Stage 5: Kidney failure, or end stage renal disease (ESRD). GFR is less than 10 ml/min. The average length of time to progress from Stage 1 to Stage 4 kidney disease is 17 years for a person with type 1 diabetes. The average length of time to progress to Stage 5, kidney failure, is 23 years.

Screening for Diabetic NephropathyScreening for Diabetic Nephropathy

Test When Normal Range

BloodPressure1

Each office visit <130/80 mm/Hg

UrinaryAlbumin1

Type 2: Annuallybeginning at diagnosisType 1: Annually, 5-yearspost-diagnosis

<30 mg/day<20 g/min<30 g/mgcreatinine

1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004

STAGES OF DIABETIC NEPHROPATHY STAGES OF DIABETIC NEPHROPATHY

Stage ofnephropathy

Urine dipstick for protein

Urine ACR(mg/mmol)

24-hour urine for albumin

Normal Negative < 2.0 men< 2.8 women

< 30 mg/day

Microalbuminuria Negative 2.0 - 20 men2.8 - 28 women

30 - 300 mg/day

Overt nephropathy(macroalbuminuria)

Positive > 20 men> 28 women

> 300 mg/day

Positive > 66.7 men> 93.3 women

> 1000 mg/day

WHEN: Type 1 - annually after puberty and 5 years of DM

Type 2 - at diagnosis and then annually

WHAT: random urine ACR;

and random urine dipstick

Normal

< 2.0 mg/mmol men

< 2.8 mg/mmol women

Rescreen in 1 year Microalbuminuria

2.0 - 20 mg/mmol men

2.8 - 28 mg/mmol women

Macroalbuminuria

> 20 mg/mmol men

> 28 mg/mmol women

Diabetic nephropathy diagnosed

Up to 2 repeat random urine ACRs performed 1

week to 2 months apart

Suspicion of nondiabetic

renal disease?

Yes

Workup or referral for

nondiabetic renal diseaseNo

Check ACR results

Only 1 abnormal ACR: Repeat

screen in 1 year

Any 2 abnormal out of 3 ACRs:

Diabetic nephropathy diagnosed

SCREENING FOR NEPHROPATHY

Priorities for vascular and renal protectionPriorities for vascular and renal protection

Clinical Issue Target Population Interventions

Vascular protection

All people w/DM ACE inhibitor, ASA, BP control, glycemic control, lifestyle modification, lipid control, smoking cessation

Elevated BP All people w/DM with hypertension (regardless of whether nephropathy is present)

Rx according to hypertension guidelines

Renal protection All people w/DM with nephropathy (even in the absence of hypertension)

Rx according to nephropathy guidelines

Treatment of Diabetic NephropathyTreatment of Diabetic Nephropathy

• Hypertension Control - Goal: lower blood pressure to <130/80 mmHg

– Antihypertensive agents• Angiotensin-converting enzyme (ACE) inhibitors

– captopril, enalapril, lisinopril, benazepril, fosinopril, ramipril, quinapril, perindopril, trandolapril, moexipril

• Angiotensin receptor blocker (ARB) therapy – candesartan cilexetil, irbesartan, losartan potassium,

telmisartan, valsartan, esprosartan

• Beta-blockers

• 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

• Restrict dietary protein to RDA of 0.8 g/kg body weight per day

Treatment of Diabetic Nephropathy (cont.)

Treatment of Diabetic Nephropathy (cont.)

Treatment of End-Stage Renal Disease (ESRD)

Treatment of End-Stage Renal Disease (ESRD)

There are three primary treatment options for individuals who experience ESRD:

1. Hemodialysis

2. Peritoneal Dialysis

3. Kidney Transplantation

HemodialysisHemodialysis

• Procedure

– A fistula or graft is created to access the bloodstream

– Wastes, excess water, and salt are removed from blood using a dialyzer

– Hemodialysis required approx. 3 times per week, each treatment lasting 3-5 hrs

– Can be performed at a medical facility or at home with appropriate patient training

• Hemodialysis Diet

– Monitor protein intake– Limit potassium intake– Limit fluid intake– Avoid salt– Limit phosphorus intake

• Complications

– Infection at access site– Clotting, poor blood flow– Hypotension

Hemodialysis (cont.)Hemodialysis (cont.)

Peritoneal DialysisPeritoneal Dialysis

• Procedure– Dialysis solution is transported into the abdomen through a

permanent catheter where it draws wastes and excess water from peritoneal blood vessels. The solution is then drained from the abdomen.

– Three Types of Peritoneal Dialysis

• Continuous Ambulatory Peritoneal Dialysis (CAPD)• Continuous Cycler-Assisted Peritoneal Dialysis (CCPD)• Combination CAPD and CCPD

Peritoneal Dialysis (cont.)Peritoneal Dialysis (cont.)

• Peritoneal Dialysis Diet

– Limit salt and fluid intake– Consume more protein– Some potassium restrictions– Reduce caloric intake

• Complications– Peritonitis

Kidney TransplantKidney Transplant

• Procedure

– A cadaveric kidney or kidney from a related or non-related living donor is surgically placed into the lower abdomen.

– Three factors must be taken into consideration to determine kidney/recipient match:

• Blood type• Human leukocyte antigens (HLAs)• Cross-matching antigens

Kidney Transplant (cont.)Kidney Transplant (cont.)

• Kidney Transplant Diet– Reduce caloric intake– Reduce salt intake

• Complications/Risk Factors– Rejection– Immunosuppressant side effects

• Benefits– No need for dialysis– fewer dietary restrictions– higher chance of living longer

How Can You Prevent Diabetic Kidney Disease?

How Can You Prevent Diabetic Kidney Disease?

• Maintain blood pressure <130/80 mm/Hg• Maintain preprandial plasma glucose 90-

130 mg/dl• Maintain postprandial plasma glucose

<180 mg/dl• Maintain A1C <7.0%

ReferencesReferencesAmerican Diabetes Association: Nephropathy in Diabetes (PositionStatement). Diabetes Care 27 (Suppl.1): S79-S83, 2004

National Kidney and Urologic Diseases Information Clearinghouse.Kidney Disease of Diabetes. Bethesda, MD: National Institute ofDiabetes and Digestive and Kidney Diseases, National Institutes ofHealth (NIH), DHHS; 2003.

United States Renal Data System. USRDS 2003 Annual DataReport. Bethesda, MD: National Institute of Diabetes and Digestiveand Kidney Diseases, National Institutes of Health (NIH), DHHS;2003.

DeFronzo RA: Diabetic nephropathy: etiologic and therapeuticconsiderations. Diabetes Reviews 3:510-547, 1995

National Kidney and Urologic Diseases Information Clearinghouse.Kidney Failure: Choosing a Treatment That’s Right For You.Bethesda, MD: National Institute of Diabetes and Digestive andKidney Diseases, National Institutes of Health (NIH), DHHS; 2003.

THANK YOUTHANK YOU