Diabetes And Kidney

Slide 1: Diabetes and Kidney

Slide 2: Normal Kidney Diabetic Kidney

Slide 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

Slide 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.

Slide 5: Diabetic Nephropathy Clinical syndrome consisting of – Protein in urine – High BP – Decline in renal function If > 25 years elapse - unlikely to develop nephropathy.

Slide 6: Proteinuria Protein (mg) Albumin (mg) Normal 30-150 10-30 Micro <500 <300 Macro >500 >300 Nephrotic range >3000 No need to check

Slide 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)

Slide 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

Slide 9: Strict glycemic control prevents microalbuminuria in type 1

Slide 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

Slide 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.

Slide 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

Slide 13: Ca - PO4 metabolism To be tackled early to prevent secondary hyperparathyroidism AIM – Ca ~ 10, PO4 < 5.5 , Ca X PO4 < 55 – Ca supplementation 1 - 1.5 gm / day CaCO3 - 40 % elemental Ca Ca acetate 20 % Ca with meals will act as PO4 binder To be given empty stomach for Ca suppl. – Vit D3 0.25 – 1 g /day If PO4 very high, to be reduced first

Slide 14: Anaemia May occur when GFR < 50 % & almost always present when GFR < 30 % Correct deficiencies – Iron, Folic acid, Vit B12, 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

Slide 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

Slide 16: Options of Renal Replacement Therapies Dialysis – Hemodialysis – Peritoneal dialysis Continuous Ambulatory Peritoneal Dialysis Continuous Cyclic Peritoneal Dialysis Renal Transplantation Simultaneous Pancreas Kidney Transplantation

Slide 17: Renal replacement therapy Very expensive Hemodialysis (HD) - Rs. 12 - 15000 / mo Peritoneal dialysis (PD) - Rs. 20000 / mo Renal Transplantation - 3 - 3.5 Lakhs for first year p Not funded by the Government p Not covered by insurance Hence the real need to prevent diabetic ESRD

Slide 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.