Diabetes And Kidney

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Diabetes And Kidney

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

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