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
Five 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.) 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 Nephropathy 1 American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004
STAGES OF DIABETIC NEPHROPATHY Stage of nephropathy 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 men 2.8 - 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 disease No 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 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 Nephropathy
Hypertension Control - Goal: lower blood pressure to <130/80 mmHg