Your SlideShare is downloading. ×
Diabetic Nephropathy
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Diabetic Nephropathy

2,561
views

Published on


0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
2,561
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
126
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. DIABETIC NEPHROPATHY
    Upendra Reddy. K
    2010H146037H
    4/2/2011
    1
  • 2.
    • Diabetes has become the most common single cause of end-stage renal disease (ESRD).
    • 3. Accounts for over one-third of all patients who are on dialysis.
    • 4. About 20–30% of patients with type 1 or type 2 diabetes develop evidence of nephropathy.
    4/2/2011
    2
  • 5. Epidemiology
    Type 1 Diabetic
    • 25 - 45% will develop diabetic nephropathy
    • 6. 80 - 90% with micro albuminuria will progress to overt diabetic nephropathy in 5 - 10 years
    • 7. nearly 100% with gross proteinuria will progress to ESRD in 7 - 10 yrs
    4/2/2011
    3
  • 8. Epidemiology
    Type 2 Diabetic
    • 50% will have micro albuminuria at the time of presentation with hypertension
    • 9. 10-20% with micro albuminuria will progress to overt nephropathy.
    • 10. Minority populations have a 2 to 20-fold higher incidence of diabetic nephropathy.
    4/2/2011
    4
  • 11. RiskFactors:
    • Age, Race, Ethnicity
    (native Americans, Mexican Americans, African Americans)
    • History of micro albuminuria
    • 12. Hypertension
    • 13. Poor glycemic control
    • 14. Smoking
    • 15. Family history of nephropathy.
    4/2/2011
    5
  • 16. StagesofDiabeticNephropathy
    • Stage I – Hyper filtration - increased blood flow through the kidney, early renal hypertrophy
    • 17. Stage II - Glomerular lesions without clinically evident disease
    • 18. Stage III - Incipient nephropathy withmicro albuminuria - alb/cr ratio .03 - .3 or albumin 20-200 mcg/min on timed specimen
    4/2/2011
    6
  • 19. Stages of Diabetic Nephropathy
    II
    III
    I
    IV
    V
    4/2/2011
    7
  • 20. Stage IV - Overt diabetic nephropathy with proteinuria >500 mg/24 hrcreatinineclearance <70 ml/min
    Stage V – End stage renal disease (ESRD)
    - creatinine clearance <15 ml/min - creatinine = 6mg/dl
    4/2/2011
    8
  • 21. Signs & symptoms:
    Fatigue
    Protein in urine
    Foamy appearance/excessive frothing of urine
    Frequent hiccups
    Swelling of the legs
    Unintentional weight gain(from fluid build up)
    4/2/2011
    9
  • 22. Diabetic nephropathy :Diagnosis & treatment
  • 23. Screening for micro albuminuria:
    Measurement of the albumin-to-creatinine ratio in a random spot collection;
    24-h collection with creatinine, allowing the simultaneous measurement of creatinine clearance;
    Timed (e.g., 4-h or overnight) collection.
    4/2/2011
    11
  • 24. SCREENING FOR NEPHROPATHY
    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
    Suspicion of nondiabetic
    renal disease?
    Yes
    Workup or referral for
    nondiabetic renal disease
    No
    Normal
    < 2.0 mg/mmol men
    < 2.8 mg/mmol women
    Rescreen in 1 year
    Macroalbuminuria
    > 20 mg/mmol men
    > 28 mg/mmol women
    Diabetic nephropathy diagnosed
    Check ACR results
    Microalbuminuria
    2.0 - 20 mg/mmol men
    2.8 - 28 mg/mmol women
    Any 2 abnormal out of 3 ACRs: Diabetic nephropathy diagnosed
    Up to 2 repeat random urine ACRs performed 1 week to 2 months apart
    Only 1 abnormal ACR: Repeat screen in 1 year
    4/2/2011
    12
  • 25. Treatment of Diabetic Nephropathy
    Hypertension Control -Goal: lower blood pressure to <130/80 mmHg
    ACE inhibitors:
    captopril, enalapril, lisinopril, benazepril, fosinopril, ramipril, quinapril, perindopril, trandolapril, moexipril
    Angiotensin receptor blockers(ARB)
    candesartan cilexetil, irbesartan, losartan potassium, telmisartan, valsartan, esprosartan
    4/2/2011
    13
  • 26. Treatment of Nephropathy:
    • Patients starting therapy with an ACE inhibitor or ARB should be monitored at 1 to 2 weeks for significant worsening of kidney function or the development of significant hyperkalemia. Serum creatinine typically rises up to 30% above baseline after initiating an ACE inhibitor or ARB, and usually stabilizes after 2 to 4 weeks.
    • 27. Patients who develop mild to moderate hyperkalemia should receive nutritional counseling regarding a potassium-sparing diet and consideration should be given to the use of non-potassium-sparing diuretics.
    4/2/2011
    14
  • 28. TREATMENT
    • Second-line renal protective agents (non-dihydropyridine calcium channel blockers) can be considered in those unable to tolerate an ACE inhibitor or an ARB.
  • TREATMENT OF NEPHROPATHY
    Choose 2nd line therapy: ACE +
    ARB or add non-DHP CCB
    YES
    Already on ACE inhibitor?
    NO
    YES
    On first-line nephropathy
    drug?
    YES
    First line drug at
    maximum dose?
    NO
    NO
    NO
    Add first-line drug;
    Recheck ACR in 2
    weeks to 2 months
    Titrate up; recheck ACR in
    2 weeks to 2 months
    ACR normal?
    Yes
    Remeasure ACR in 1 year
    First line drugs:
    Type 1- ACE inhibitor
    Type 2 with Cr Cl > 60 mL/min - ACE inhibitor or ARB
    Type 2 with Cr Cl  60 mL/min - ARB
    4/2/2011
    16
  • 29. Ongoing clinical trials:
    4/2/2011
    17
  • 30. References:
    • American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care. 2010 Jan;33 Suppl1:S11-61
    • 31. American Diabetes Association (2004). Nephropathy in diabetes. Clinical Practice Recommendations 2004. Diabetes Care. 27(Suppl 1): S79–S83
    • 32. DeFronzo RA: Diabetic nephropathy: etiologic and therapeutic considerations. Diabetes Reviews 3:510-547, 1995
    • 33. www.clinicaltrials.gov.in
    4/2/2011
    18