Management of dm in ckd


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Management of dm in ckd

  1. 1. MANAGEMENT OF <br />DIABETES MELLITUS <br />IN CKD<br />by<br />Dr.SridharDM (nephrology)<br />
  2. 2. Diabetes:TheMost Common Cause of ESRD<br />Diabetes<br />Hypertension<br />50.1%<br />27%<br />Primary Diagnosis for Patients Who Start Dialysis<br />Glomerulonephritis<br />Other<br />No. of patients<br />13%<br />10%<br />700<br />Projection<br />95% CI<br />600<br />500<br />400<br />No. of dialysis patients (thousands)<br />520,240<br />300<br />281,355<br />200<br />243,524<br />100<br />r2=99.8%<br />0<br />1984<br />1988<br />1992<br />1996<br />2004<br />2000<br />2008<br />
  3. 3. Comorbidities <br />%Stroke/TIA<br />%Heart Failure<br />%ASHD<br />%Amputation/PVD<br />
  4. 4. Causes of renal disease in diabetes<br />Diabetic nephropathy<br />Renal artery stenosis<br />Myeloma, outflow obstruction, polycystic renal disease, glomerulonephritis, etc<br />Drugs <br />NSAIDS/Cox 2 inhibitors<br />Fibrates<br />ACEI, ARBs<br />
  5. 5. Diabetic Nephropathy<br />30% of all end-stage renal disease <br />Increased co-morbidity and mortality – retinopathy, cardiovascular disease, stroke, peripheral vascular disease<br />May be prevented/delayed by early screening and treatment<br />
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  10. 10. Factors affecting progression of nephropathy<br />Blood pressure<br />Urinary protein excretion<br />(glycaemic control)<br />
  11. 11. Minimum screening for renal disease in Diabetes<br />Annual EMU for ACR. Repeat within a month if positive, in absence of UTI/renal stones/other renal disease<br />Annual serum creatinine<br />Creatinine<br />eGFR(preferred MDRD equation)<br />
  12. 12. microalbuminuriaand proteinuria<br />Diagnosis of microalbuminuria based on 2 out of 3 positive first passed morning urine samples in absence of urinary tract infection<br />
  13. 13. Initial assessment of patient with diabetes and renal impairment<br />Is this likely to be diabetic nephropathy?<br />Presence of retinopathy<br />Microalbuminuria/proteinuria<br />Is this likely to be renal artery stenosis?<br />Family history, Drug history, GU history etc<br />AIP, myeloma screen, PSA<br />Ultrasound<br />
  14. 14. Metformin<br />Metformin has been used in low doses in patients with glomerular filtration rate (GFR) as low as 30 to 60 ml/min. It <br />should not be used at a GFR below 30 ml/min -- risk for lactic acidosis.<br />As renal function can deteriorate abruptly, <br />better to avoid metformin once serum creatinineconcentration rises above <br /> 1.5 mg/dl (132 μmo/l) in men <br /> 1.3 mg/dl (117 μmol/l) in women<br />ORAL HYPOGLYCEMICS<br />
  15. 15. Insulin secretagogues(sulfonylurea and meglitinides)<br />Sulphonylureas (especially gliblenclamide) may accumulate as renal function deteriorates<br />can be associated with hypoglycemia<br />Glycosidase inhibitors<br /><ul><li>contraindicated in renal failure</li></li></ul><li>Thiazolidinediones<br />associated with weight gain, (fluid retention + nonfluid gains)<br />patients at risk for congestive heart failure -- should be avoided. <br />Concern about increased bone fracture rates in patients using thiazolidinediones,<br />could potentiate CKD - related bone disease.<br />
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  17. 17. insulin<br />Insulin regimens are the most commonly used to control glycemiain CKD<br />increasing half-life of insulin as CKD progresses, the risk for hypoglycemia increases.<br />Insulin requirements decrease further in HD patients, particularly in those with residual diuresis (<500 ml/day), <br />Insulin requirement often decreases by 30%<br />In peritoneal dialysis (PD) patients, <br />intraperitonealinsulin is more physiologic than subcutaneous, as portal absorption of insulin may better mimic the endogenous insulin effect. <br />Insulin requirements typically increase by 200% to 300% in this situation<br />
  18. 18. Insulin in pt. on hemodialysis<br />Insulin inhibitors – dialyzable<br />Insulin resistance diminishes after the start of dialysis. <br />half-life of insulin is prolonged. <br />the potential for hypoglycemia with both oral agents and insulin increases in the presence of CKD (with the exception of gliquidoneand glimepiride). <br />Self-monitoring of blood glucose concentration is imperative.<br />Insulin requirement often decreases by ~30%<br />Glargine has been shown to reduce hypoglycemia in hemodialysis patients<br />
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  20. 20. BLOOD PRESSURE CONTROL<br />BP reduction in type 1 & type 2 DM patients reduces rate of CKD progression <br />At any given level of GFR, blood pressure tends to be higher in diabetic than in nondiabeticpatients with CKD<br />recommended blood pressure target 125/75 mm Hg<br />Ideally – (typically takes three or four drugs to accomplish)<br />start with an ACEinhibitor or ARB<br />Add diuretic<br />Add calcium channel blocker, β-blocker, or renin inhibitors<br />
  21. 21. If Blood Pressure >125/75 mm Hg in Diabetes or Chronic Kidney Disease with Any Level of Albuminuria<br />(if systolic BP >20 mmHg above goal)<br />START with ACEI or ARB/thiazide diuretic*)<br />(if systolic BP< 20 mmHg above goal)<br />Start ARB or ACE Inhibitor titrate upwards<br />Recheck within 2-3 weeks<br />If BP Still Not at Goal (125/705mm Hg)<br />Add Long Acting Thiazide Diuretic* <br /> Add CCB or b blocker** (titrate dose upward)<br />Recheck within 2-3 weeks<br />If BP Still Not at Goal (125/75 mm Hg) <br />Consider low dose aldosterone antagonists#<br />or<br />If used CCB, Add Other Subgroup of CCB(ie, amlodipine-like agent if verapamil or diltiazem already being used and the converse)<br />OR if b blocker used add CCB<br />Recheck within 4 weeks<br />If BP Still Not at Goal (125/75 mm Hg)<br />Add Vasodilator (hydralazine, minoxidil) <br />
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  23. 23. <ul><li>ACEI/ARB
  24. 24. begin at a low dose;
  25. 25. increase dose at 4-week intervals to reduce microalbuminuria
  26. 26. antiproteinuric effects not necessarily attained at antihypertensive doses
  27. 27. increase dose until proteinuria reduced by 30 to 50%
  28. 28. Titrate to maximal suppression of urinary albumin excretion for DM patients with persistent microalbuminuria despite intensive insulin therapy even without HTN
  29. 29. titration limited by adverse effects:</li></ul>an acute increase in serum creatinine of 50% or more; <br />renal artery stenosis;<br />hypovolemia; congestive heart failure<br />hyperkalemia resistant to corrective maneuvers<br />ARB : consider for subjects with documented aldosterone escape<br />
  30. 30. Impact of diabetes on dialysis Blood pressure management<br />Autonomic Insufficiency<br />BP drops and very labile<br />Medial Calcificaton<br />Wide pulse pressure<br />Hypertensive Cardiomyopathy<br />Preload <br />Cardiac function<br />After load<br />
  31. 31. Lipid control<br />Heart Protection Study<br />Patients with DM and CKD who received statins had a 23% decrease in cardiovascular risk with an absolute event reduction of 80%<br />In HD patients with type 2 DM, the addition of 20 mg of atorvastatin <br />40% decrease in lowdensitylipoprotein cholesterol levels & significant decrease in cardiac events<br />
  32. 32. Dosages of statins In ckd<br />IN PT.S ON HEMODIALYSIS AND PERITONEAL DIALYSIS<br />Atorvastatin - up to 80 mg/day <br />Fluvastatin– up to 80 mg/day. <br />Pravastatin- limited to 10 mg, as active metabolites can accumulate,<br /> Pravastatin Pooling Project - of up to 40 mg were safely (GFR of 30 ml/min per 1.73 m2)<br />Simvastatin – upto 20 mg/day (40-mg/day in stage 3 CKD (Heart Protection Study))<br />Rosuvastatin - not more than 10 mg/day when GFR falls below 30 ml/min per 1.73 m2.<br />Ezetimibe - safely used (effects absorption mainly bile acid sequestrants)<br />Fenofibrate - reduced by one third in CKD stage 2, <br /> reduced by two thirds in CKD stages 3 and 4<br /> avoided in CKD stage 5.<br />Gemfibrozil - safely used, although in PD, elevated CPK levels have been reported <br />Niacin(Sustained-release)- should be decreased by 50% at CKD stage 5<br />
  33. 33. DIET IN CKD PT.S WITH DM<br />Diabetic patients with renal failure are often severely catabolic and tend to develop malnutrition<br />Reduction of dietary protein intake to 0.8 g/kg body weight for CKD Stages 1–4 is recommended<br />Increase protien intake >1.2g/kg in HD >2.0g/kg in PD <br />ANEMIA<br />Anemia occurs at an earlier stage of CKD in DM patients and is often more severe<br />Erythropoietin - Anemia associated with CKD <br />In DM - higher dosages compared with nonDMpt.s<br />
  34. 34. Diabetic patients with CKD develop secondary hyperparathyroidism at a slower rate than nondiabetics<br />predisposed to low-turnover (adynamic) bone disease - risk factor for cardiovascular calcification<br />care should be taken to avoid calcium loading. <br />Accumulate aluminum more readily and are more susceptible to aluminum-induced bone disease. <br />Aluminum containing phosphate binders should always be avoided in the diabetic patient with advanced CKD<br />Target serum phosphorus goal <br />< 5.5 mg/dl in patients with Stage 5 CKD<br />< 4.6 mg/dl in Stage 3–4 CKD.<br />if the i-PTH is abnormal - evaluate for vitamin D deficiency <br />measurement of 25-hydroxy vitamin D.<br />
  35. 35. Diabetic Management in ckd<br />Parameter<br />Lower BP………………………<br />Block RAAS……………………<br />Improve glycemia …………….<br />Lower LDL cholesterol………..<br />Anemia management ………...<br />Endothelial protection…………<br />Smoking………………………..<br />Target<br />< 125/75 mmHg<br />ACEi or ARB to max tolerated<br />A1c < 6.5% (Insulin/TZD)<br />< 100 (70) mg/dl statin + other<br />Hb 11-12 g/dl (Epo + iron)<br />Aspirin daily<br />Cessation<br />
  36. 36. RENAL replacement therapy in ckd with dm<br />Start dialysis at eGFR - 15 ml/min per 1.73 m2 (normally - eGFR <7-8) <br />they tend to tolerate uremia poorly and frequently have sodium retention and fluid overload.<br />Peritoneal dialysis–associated glucose loading<br />Replace glucose solutions in part by amino acid solutions and polyglucose. <br />Loss of solute and water transport often limits long-term use of peritoneal dialysis to 3 to 5 years. <br />Switching to hemodialysis should be considered before volume overload or uremic symptoms occur<br />Pt.s on PD, Glucose meters based on GLUCOSE OXIDASE TEST should be used <br />maltose and polyglucose present in PD solution, affect glucose dehydrogenase–based glucose meters<br />
  37. 37. Transplants<br />Type 1 DM - pancreas transplant<br />Can induce regression of moderate Diabetic Nephropathy lesions in native kidneys<br />but only during a period of 10 years after transplantation.<br />Pancreas transplantation at the time of renal transplantation <br />Prevents / slows the development of Diabetic Nephropathy in the transplanted kidney.<br />
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  39. 39. Thank you<br />