Continuing Education:
Renal and DiabetesAlisa McAleer, Dietetic Intern
December 15, 2014
Southern Regional Medical Center
Outline
• Chronic Kidney Disease and Diabetes
• Recommendations & guidelines: Glycemic Control and Protein
• For the practicing RDN
• Patient education and counseling
Chronic Kidney Disease (CKD)
• CKD definition: Abnormalities of kidney structure or function, present for
> 3 months, with implications for health
• The most common cause of kidney failure ???
• Latter stages of Chronic Kidney Disease (CKD)
• 35%- Adults with Diabetes
Diabetic Nephropathy
• Diabetic nephropathy (DN)
• Glomerular hypertrophy
• Transient hyperfiltration
• Proteinuria
• Renal fibrosis
• Decreased glomerular filtration rate (GFR)
• Prevalence
• African Americans, Asians, Native Americans
• Risk factors
• Poor glycemic control, hypertension, tobacco use, age of onset
Kidneyabc.com
Diabetic
Nephropathy
Albuminuria
Stages• Stage – A1
• <30 mg/24hrs (Normal)
• Stage – A2
• 30-300 mg/24hrs (Moderately increased albumin urinary excretion)
• Stage – A3
• >300 mg/24hrs (Severely increased albumin urinary excretion)
Screening
• Type 1 Diabetes
• 5 years after diagnosis
• Type 2 Diabetes
• Upon initial diagnoses
Renal & Diabetes
Current Regulations and Guidelines
Glycemic Control
• Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE)
• Subjects (randomized)
• Tight glycemic control (Hgb A1c <6.5%)
• Standard control
• 10% risk reduction in macro/microvascular events
• 21% reduction in nephropathy
• Meta-analysis published in 2012
• Tight glycemic control reduces overall albuminuria
• Target goal A1c <7%
Low Protein Diet
• Low-Protein and Diabetic
Nephropathy: Meta-analyses
• LPD – 0.6-0.8 g/kg/day
• Control – 1-1.6g/kg/day
• Actual Protein Intake Ratio (APIR)
• Protein intake
• Diet compliance
• Protective effects
• Improved eGFR & proteinuria
• No negative impact on glycemic
control
• Sustainable intervention is key!
CKD: Protein Intake for Diabetic
Nephropathy:
Academy Supported Evidence• WHAT ARE THE PROTEIN REQUIREMENTS TO MINIMIZE DISEASE
PROGRESSION WHILE MAINTAINING ADEQUATE NUTRITION STATUS IN ADULT NON-DIALYZED PATIENTS WITH DIABETIC NEPHROPATHY?
• CKD: Protein Intake for Diabetic Nephropathy
• For adults with diabetic nephropathy, the RD should recommend or prescribe a protein-controlled diet providing 0.8g to 0.9g of protein per kg of body weight per day. Providing dietary protein at a level of 0.7g per kg of body weight per day may result in hypoalbuminemia and potential risk of malnutrition. Research reports that protein-restricted diets improved microalbuminuria.
• American Diabetes Association: 0.8g/kg
Renal and Diabetes
The RDN
RDN Skill Level
• Competent, proficient and expert
• Certificate of Training Program in CKD Nutrition Management
• CDR’s Board Certification in Renal Nutrition
Diet Intervention
• Kidney disease
• Uremia
• Hypertension
• Edema
• Hyperkalemia
• Hyperlipidemia
• Blood glucose
Patient Education and Counseling
• Obesity
• Increased risk for DN
• Hyperlipidemia
• Coronary disease – lipid management
• Vitamin D therapy
• RAAS and albuminuria
• Antioxidants
• Not recommended as a treatment
Patient Education and Counseling
• Carbohydrate Counting
• Keep cholesterol level under control
• Limit protein to a healthy level based on individualized recommendations
(CAUTION)
• Limit sodium intake, <2 grams
Summary
• Early detection
• Proper screening
• Management
References
• Academy of Nutrition and Dietetics Evidence Analysis Library. (n.d.). CKD: protein intake for diabetic nephropathy. Retrieved December 7, 2014, from andeal.org: http://www.andeal.org/template.cfm?template=guide_summary&key=2409
• American Diabetes Association. (2014). Nephropathy in diabetics (Position statement). Diabetes Care, 37(12).
• Franz, M. J., Powers, M. A., Leontos, C., Holzmeister, Kulkarni, K., Monk, A., . . . Gradwell, E. (2010, December). The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. Journal of the American Dietetic Association, 110(12), 1852-1889. doi: http://dx.doi.org/10.1016/j.jada.2010.09.014
• Kent, P. S., McCarthy, M. P., Burrowes, McCann, L., Pavlinac, J., Goeddeke-Merickel, C. M., . . . Benner, D. (2014). Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 standards of practice and standards of professional performance for Registered Dietitian Nutritionists (competent, proficient and expert) in nephrology nutrition. Journal of the Academy of Nutrition and Dietetics, 1448-1503.
• Kowalski, A., Krikorian, A., & Lerma, E. V. (2014). Diabetic nephropathy for the primary care provider: new understandings on early detection and treatment. The Ochsner Journal, 14(3), 369-379.
• Lowth, M. (2013). Chronic kidney disease - an update. Practice Nurse, 43(1), 34-39.
• Mahan, K. E.-S. (2012). Krause's food and the nutrition care process. St. Louis, MO: Elsevier.
• Nezu, U., Kamiyama, H., Kondo, Y., Sakuma, M., Morimoto, T., & Ueda, S. (2013, April 25). Effect of low-protein diet on kidney function in diabetic nephropathy: meta-analysis of randomised controlled trials. BMJ Open. doi:10.1136/bmjopen-2013-002934
• Steves, P. (2013). Evaluation and managment of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Annals of Internal Medicine, 825-830.
• Supplement: summary of recommendation statements. (2013). Kidney International, 3, 5-14. doi:10.1038/kisup.2012.77