Diabetic Nephropathy

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Diabetic Nephropathy

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

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