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Diabetes And Kidney

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  • 1. Diabetes and Kidney
  • 2. Diabetic Kidney Normal Kidney
  • 3. Diabetic nephropathy
    • Commonest cause of Renal failure
    • 50 % of dialysis patients have DM
    • 30 % of patients with type 1 & 2 develop renal failure
    This number will increase as the diabetic population is increasing
  • 4. Risk factors for developing Diabetic Nephropathy
    • Poor control of blood glucose,
    • Long duration of Diabetes,
    • Presence of other diabetic complication,
    • Ethnicity (Asian, Pima Indians),
    • Pre-existing High BP,
    • Family h/o of Diabetic Nephropathy,
    • Family h/o Hypertension.
  • 5. Diabetic Nephropathy
    • Clinical syndrome consisting of
      • Protein in urine
      • High BP
      • Decline in renal function
    • If > 25 years elapse - unlikely to develop nephropathy.
  • 6. Proteinuria No need to check >3000 Nephrotic range >300 >500 Macro <300 <500 Micro 10-30 30-150 Normal Albumin (mg) Protein (mg)
  • 7. Microalbuminuria
    • Called micro… because it is not detectable by normal urine dip stick
    • Urinary albumin (30 - 300 mg/day)
    • Becomes irreversible when reaches 300
    • Detected by newer generation dipstix (micral)
  • 8. Screening for microalbuminuria
    • Whom to screen
      • Type 1 DM, from 5 years from diagnosis,
      • Annually from diagnosis
    • Abnormal tests
      • Exclude recent vigourous exercise, fever, heart failure, urine infection, Prostatitis and menstruation,
      • Confirm observation twice,
      • Look for hypertension
  • 9. Strict glycemic control prevents microalbuminuria in type 1
  • 10. Hypertension
    • BP of < 130 / 80 is ideal
      • Prevents progression of Renal Failure
      •  myocardial hypertrophy
    • ACE I / ARBs - drugs of choice
      • Use with caution if S.Creatinine > 3 mg
    • Choice depends on comorbid conditions too
      •  blocker in CAD
  • 11. Diet
    • Calories - 35 K cal / kg
    • Proteins of high quality - 0.8 gm / kg
    • Salt - 4 - 5 gm / day
    • Potassium - 50 - 60 meq/day
    • Lipids 30 % of calorie intake.
  • 12. Fluid management
    • Many diabetics have nephrotic state and severe edema and need rigorous salt & fluid restriction
    • Severe edema - 600 - 800 ml / day
    • Mild to moderate - equal to UOP
    • No edema - UOP + insensible
    • losses
  • 13. Ca - PO 4 metabolism
    • To be tackled early to prevent secondary hyperparathyroidism
    • AIM
      • Ca ~ 10, PO 4 < 5.5 , Ca X PO 4 < 55
      • Ca supplementation 1 - 1.5 gm / day
        • CaCO 3 - 40 % elemental Ca
        • Ca acetate 20 %
        • Ca with meals will act as PO 4 binder
        • To be given empty stomach for Ca suppl.
      • Vit D 3 0.25 – 1  g /day
    • If PO 4 very high, to be reduced first
  • 14. Anaemia
    • May occur when GFR < 50 % & almost always present when GFR < 30 %
    • Correct deficiencies
      • Iron, Folic acid, Vit B 12 , Pyridoxine
    • Erythropoietin 75 - 150 iu/kg SC
      • With Iron supplements
      • Expensive therapy Rs. 8 - 10, 000 / month
      • Hb % maintained at 11 - 12
        • > 13 in pts with CAD
  • 15. Others
    • Lipid lowering - diet, statins
    • Low dose aspirin
    • Avoid nephrotoxic drugs & contrast procedures
    • Prevent & treat infections energetically
    • Hepatitis B immunization
      • Early immunization ideal
      • if Cr. > 3 double & more frequent dosing
  • 16. Options of Renal Replacement Therapies
    • Dialysis
      • Hemodialysis
      • Peritoneal dialysis
        • C ontinuous A mbulatory P eritoneal D ialysis
        • C ontinuous C yclic P eritoneal D ialysis
    • Renal Transplantation
    • Simultaneous Pancreas Kidney Transplantation
  • 17. Renal replacement therapy
    • Hemodialysis (HD) - Rs. 12 - 15000 / mo
    • Peritoneal dialysis (PD) - Rs. 20000 / mo
    • Renal Transplantation - 3 - 3.5 Lakhs for first year
    • Not funded by the Government
    • Not covered by insurance
    Very expensive Hence the real need to prevent diabetic ESRD
  • 18. Conclusion
    • Pathogenesis and progression of Renal Disease in Diabetics is multifactorial and intervention should be multi-pronged
    • Glycemic control
    • Hypertension control
    • Treat dyslipdemia
    • Others
      • Diet, Smoking cessation, Exercise etc.