Protecting the Kidney in Diabetes

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Lecture at the Guam Diabetes Association meeting (8 November 2009) for patients with diabetes

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  • Izinkan sy berkongsi kisah benar mengenai arabic gum kpd Tuan/Puan.

    kisahnya macam ni.
    setahun yang lalu pakcik sy mengalami sakit buah pinggang peringkat akhir dan menjalani rawatan dialisis di Hospital Pulau Pinang. makcik sy datang dari Sudan datang menziarahi pakcik dan membawa 'Arabic Gum' untuk pakcik.
    selepas kurang 10 hulan mengamalkan makanan dari syurga ini, Alhamdulillah pakcik sembuh dari penyakit buah pinggang dan dialisis dihentikan.
    Dengan nada gembira pakcik hubungi makcik pada jun 2013 untuk ucap terima kasih dan meminta benih pohon akasia yang mengeluarkan 'Arabic Gum' itu untuk ditanam di rumah tapi sayangnya pohon akasia hanya boleh tumbuh di tempat asalnya saja iaitu sudan.

    Setelah membuat kajian kasihatan dan pasaran, sy dan makcik bersetuju untuk membawa Arabic Gum ke Malaysia dalam kuantiti yang banyak untuk tujuan beramal dan berniaga kerana cara pemakanannya amat mudah, amat murah dan paling penting ia berkesan (Dengan izin Allah).

    Tuan/Puan boleh dapatkan maklumat lanjut dgn menaipkan Arabic Gum / Getah Arab / Al Manna / Acacia Powder di Internet.
    Di negara arab ia digelar 'Bread from heaven' kerana Arabic Gum atau Al manna ini ada disebut di dalam kitab Al-Quran dalam surah Al-baqarah ayat 57.
    Info:-
    Getah Arab ini hanya terdapat di Sudan. Tidak hairanlah kenapa negara Sudan menjadi rebutan sesetengah pihak.

    Getah Arab (Gum Arabic) sejenis prebiotik asli yang hanya terdapat di Sudan mempunyai potensi dalam industri perubatan, makanan dan solek antarabangsa akan dapat menguatkan kedudukan Malaysia sebagai sebuah hab halal dengan adanya penyelidikan rapi mengenainya yang dipelopori UKM.

    Ramli, 41 tahun, adalah juga bukti khasiat getah ini kerana beliau dahulu terpaksa menjalani rawatan dilasis tiga kali seminggu kerana buah pinggangnya sudah tidak berfungsi. Berkat penggunaan getah itu selama tujuh bulan buah pinggangnya sudah puleh dan beliau sejak 10 bulan kebelakangan ini tidak lagi perlu menjalani rawatan itu.

    Prebiotik adalah sejenis makanan untuk bakteria semula jadi yang terdapat dalam perut yang menentukan pengkhadaman makanan dapat berfungsi dengan baik. Bahan ini kini terdapat dalam makanan seperti berteh, beberapa jenis roti dan juga kapsul kebanyakannya di impot dari Barat.

    Kelebihan getah Arab dari Sudan ini ialah lebih 90 peratus daripadanya adalah jenis terbaik dan diperolehi secara semula jadi dari dua jenis pohon acasia yang hanya boleh di tanam di Sudan. Usaha menanamnya di negara jiran Sudan seperti Chad dan juga di Amerika telah gagal.

    Penyelidikan Terhadap Khasiat Getah Arab di UKM
    Rabu, 29 Jun 2011
    http://www.ukm.my/news/index.php/ms/berita-kampus/758-ukms-research-into-gum-arabic-set-to-create-international-demand-for-it-.html




    Sungguh niat sy hanya ingin membantu sesama saudara islam sy atau sesisapa sahaja.
    kami menjualnya dengan harga yang amat murah RM45(untuk pos) RM40 (C.O.D = cash on delivery), boleh tahan untuk sebulan.(boleh bandingkan dgn kos rawatan dialisis sebulan).

    ruangan ini amat terbatas untuk beri penerangan dengan jelas tentang apa itu arabic gum, so jangan segan untuk hubungi sy atau sms sy pun boleh untuk dapatkan informasi lebih lanjut. insya Allah sy akan beri gambaran jelas tentang Arabic Gum ini.

    Tuan/Puan boleh hubungi sy di:
    samsurijal 0128634538
    andreaboy786@gmail.com

    sekian wassalam
       Reply 
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Protecting the Kidney in Diabetes

  1. 1. PROTECTING THE KIDNEY IN DIABETES Rey Jaime M. Tan MD, FPCP Clinical Associate Professor University of the Philippines College of Medicine Section of Nephrology, Department of Medicine UP-Philippine General Hospital
  2. 2. OUTLINE How does the kidney function? How common is Diabetic Kidney Disease (DKD)? What are the stages of DKD? How can DKD be prevented? How can the progression of DKD to Chronic Kidney Disease (CKD) be delayed?
  3. 3. The kidney
  4. 4. The kidney Filters the blood
  5. 5. The kidney Filters the blood Reabsorbs all necessary nutrients in the blood
  6. 6. The kidney Filters the blood Reabsorbs all necessary nutrients in the blood Excretes all waste products in the urine
  7. 7. The kidney
  8. 8. The kidney Involved in synthesis of hormones i.e. vitamin D, erythropoietin etc.
  9. 9. The kidney Involved in synthesis of hormones i.e. vitamin D, erythropoietin etc. Maintains balance in electrolytes, acids and bases
  10. 10. The nephron Functional unit of the kidney 1,000,000 nephrons per kidney
  11. 11. Diabetic Kidney Disease A Complication of Diabetes Leading cause of blindness in adults 2 to 4-fold 24000 new cases increase in stroke each year in US Diabetic Stroke Leading cause of Retinopathy end-stage renal disease in adults 44% new cases/yr Diabetic Nephropathy Cardiovascular Disease Leading cause of non-traumatic 8 out of 10 diabetic limb amputations patients die from 60% new cases/ cardiovascular events yr Diabetic 5-10 year reduction Neuropathy in life expectancy NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2006.
  12. 12. Natural History of Type 2 Diabetic Kidney Disease Clinical type 2 diabetes Functional changes* Structural changes† Rising blood pressure Microalbuminuria Proteinuria Rising serum creatinine levels End-stage renal disease Cardiovascular death Onset of 2 5 10 20 diabetes Years * Renal hemodynamics altered, glomerular hyperfiltration. † Glomerular basement membrane thickening ↑, mesangial expansion ↑, microvascular changes +/-.
  13. 13. Philippine NNHeS 2003-2004 Renal Report Microalbuminuria This is equivalent to 8,626,027 Filipinos Prevalence of microalbuminuria was 18.5%
  14. 14. Philippine NNHeS 2003-2004 Renal Report Macroalbuminuria At least +1 proteinuria using the Multiple Reagent Strip for Urinalysis® (Bayer Corporation) Prevalence of macroalbuminuria was 4.2%
  15. 15. How Protein Spills into the Urine diabetic kidney walls of the glomerulus allow proteins to escape frothy urine
  16. 16. Primary Renal Disease among Filipino Patients on Dialysis (Chronic Kidney Disease) 2005 2006 2007 2008 4000 3000 2000 1000 0 Glomerulonephritis Diabetic Hypertensive Kidney Disease Nephrosclerosis Philippine Renal Disease Registry 2006 -2009 reports
  17. 17. Increasing Prevalence of Chronic Kidney Disease (CKD) Increasing prevalence expected Aging population Global epidemic of type 2 diabetes 1 Patients with stage 1-4 CKD outnumber patients with stage 5 CKD by ~50:1 in the US 2 1. El Nahas & Bello. Lancet. 2005;365:331-340 2. Coresh et al. Am J Kidney Dis. 2003;41:1-12
  18. 18. Increasing Prevalence of Chronic Kidney Disease (CKD) >1 million patients with CKD on dialysis worldwide Approximately 250 000 new patients diagnosed with CKD each year 3 3. Moeller et al. Nephrol Dial Transplant. 2002;17:2071-2076
  19. 19. Stages in Progression of CKD Complications Increased ↓ GFR Kidney CKD Normal Damage risk failure death Screening CKD risk Diagnosis & Estimate Replacement for CKD risk reduction; treatment; progression; by dialysis and factors, i.e. Screening Treat comorbid Treat transplant diabetes for CKD conditions; Slow complications; progression Prepare for replacement
  20. 20. Five Stages of Kidney Disease 1 2 3 4 5 Macro- ↑↑ urine Hyper- End stage Micro- albuminuria protein filtration renal albuminuria ↑ BUN, Crea, ↑↑ BUN, ↑ kidney size disease BP Crea, BP GFR >90 GFR 60-89 GFR 30-59 GFR 15-29 GFR <15 ml/min ml/min ml/min ml/min ml/min
  21. 21. National Statistics Office Kidney disease is now the #10 cause of mortality in the Philippines
  22. 22. Delaying Progression of DKD to CKD A B C D ACE- Blood Cholesterol Diet inhibitors/ Pressure ARBs E F G H Educate Fasting Glass of Hemoglobin blood sugar water
  23. 23. A ACE- inhibitors/ ARBs ACE inhibitors: captopril, enalapril, lisinopril, perindopril etc. Angiotensin II Receptor Blockers (ARBs): losartan, irbesartan, olmesartan, telmisartan, reytan etc. Very good antihypertensives, especially in combination with other drugs For kidney protection: reduces protein spillage in the urine
  24. 24. Benefits of ACE Inhibitors Reduces risk of heart attack and stroke Works well with other antihypertensive medications like calcium channel blockers (i.e. amlodipine) and diuretics (thiazides) Common side effects: cough, angioedema
  25. 25. B Blood Pressure Target BP for diabetics <130/80 mm Hg Target BP for diabetics with kidney disease <125/75 mm Hg
  26. 26. The closer to normal BP levels are, the better! Ischemic heart disease rates by SBP, DBP and age Systolic Blood Age at risk: Diastolic Blood Age at risk: 256 Pressure Pressure 80-89 years 256 80-89 years 128 128 70-79 years 70-79 years 64 64 60-69 years 60-69 years IHD 32 32 mortality 50-59 years 50-59 years 16 16 (floating 40-49 years 40-49 years absolute 8 8 risk and 4 4 95% CI) 2 2 1 1 120 140 160 180 70 80 90 100 110 Usual SBP (mm Hg) Usual DBP (mm Hg) CI, confidence interval; IHD, ischemic heart disease. Lewington S et al. Lancet. 2002;360(9349):1903-1913.
  27. 27. C Cholesterol Total cholesterol <200 mg/dL LDL <100 mg/dL Triglycerides <150 mg/dL HDL: >40 mg/dL >50 mg/dL
  28. 28. Association between Risk Factors and a Heart Attack INTERHEART, 2004 More Dyslipidemia vegetables and fruits Smoking Exercise Diabetes Moderate Hypertension alcohol intake Abdominal obesity
  29. 29. Relationship Between Changes in LDL-C and HDL-C and Coronary Heart Disease (CHD) Bad cholesterol Good cholesterol 1% decrease in LDL-C 1% increase reduces CHD in HDL-C risk by 1% reduces CHD risk by 3%
  30. 30. D Diet Low protein diet and very low protein diet Low salt, low fat diet
  31. 31. Protein Intake and Restriction in Diabetes High protein intake increases risk of diabetic kidney disease and progression to end-stage renal disease Diabetic patients who had lower protein intake had lower prevalence of microalbuminuria
  32. 32. Protein Intake and Restriction in Diabetes Protein restriction reduces the workload of the kidney 0.6 to 0.7 g/kg protein intake reduces the rate of fall of GFR modestly
  33. 33. Recommended Dietary Protein Intake Protein intake based on ideal body weight Minimum daily protein requirement World Health Organization 0.45 g protein per kilogram Maximum daily protein requirement US RDA and UK Department of Health & Social Security 0.8 g protein per kilogram
  34. 34. Low Protein Diet Conventional low protein diet (LPD) 0.6 g protein/kg/day 50-60% must be of high biologic value
  35. 35. Low Protein Diet Very low protein diet (VLPD) 1/2 LPD Does not provide the daily requirements for essential amino acids Supplementation is necessary
  36. 36. (Very) Low Protein Diet: A Mainly Vegetarian Diet
  37. 37. Food Not Allowed in Large Amounts Meat, fish, eggs, milk and milk products, cheese, shellfish, roe
  38. 38. Protein intake in a 60 kg person/day 0.45-0.8 grams/kg = 27 to 48 g Serving size: 1 sandwich Energy 540 cal Total fat 30 g Total carbohydrate 47 g Protein 25 g
  39. 39. Specific manufactured foods totally lacking in protein Bread Wafers Biscuits Noodles Flour
  40. 40. E Educate and Empower Educate Healthy lifestyle Smoking cessation Weight reduction and exercise Regular follow-up with your doctor Early referral to a nephrologist
  41. 41. F Strict control of Fasting FBS & HbA1c blood sugar Dietary restrictions Oral hypoglycemic agents Insulin
  42. 42. G Glass of water Eight glasses of water Essential to hydrate well What goes in must go out (>2 liters urine/day) Essential to prevent kidney stone formation Diet colas?
  43. 43. Typical Daily Water Balance in a Normal Human Water intake, ml/day Water output, ml/ Source Source day Obligatory Elective Obligatory Elective Ingested water 400 1000 Urine 500 1000 Water content 850 Skin 500 of food Water of 350 Respiratory 400 oxidation tract Stool 200 Total 1600 1000 Total 1600 1000
  44. 44. H Hemoglobin Anemia is an early sign of chronic kidney disease (reduced erythropoetin) Risk of anemia is increased 2-3x in people with diabetes
  45. 45. Stages of CKD CKD CARE ESRD End Stage Renal Disease Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 >90 60-89 30-59 15-29 <15 (& kidney (or dialysis) damage) eGFR (mL/min/1.73m2) sMDRD formula: 186 x serum creatinine-1.154 x age-0.202 x (1.212 if black) x (0.742 if female) Drüeke F. WCN, Singapore, 2005
  46. 46. Awareness of Anemia in Patients with Diabetes Aware they were at 26% risk for anemia 60% 14% Aware that they had been diagnosed with anemia 504 respondents selected from a nationally representative panel of people with diabetes
  47. 47. Awareness of anemia in MDs taking care of diabetics Unrecognized 23% anemia by WHO definition (n=190) 77% 820 patients in a diabetes clinic
  48. 48. Anemia - Definitions WHO definition Hb < 13 g/dL (male & post-menopausal females) Hb < 12 g/dL (pre-menopausal females) K-DOQI Hb < 13.5 g/dL in adult males Hb < 12 g/dL in adult females
  49. 49. Expected Benefits of Anemia Management in CKD Better quality of life Decrease in morbidity Decrease in risk for heart attack and stroke Decrease in the size of a failing heart Lower hospitalization rates Slower progression to kidney failure and dialysis Increased survival and better quality of life
  50. 50. Reversal of anemia by epoetin can retard progression of chronic renal failure 100 Hct <30%, treated with epoetin Cumulative renal survival rate (%) Hct >30%, untreated Hct <30%, untreated 80 60 40 p=0.0024 p=0.3111 p=0.0003 20 n=108 0 0 5 10 15 20 25 30 35 40 Months of follow-up Adapted from Kuriyama et al Nephron 1997; 77: 176-185
  51. 51. U Check your urine Urine Frothy urine vs clear light yellow urine frequency , dribbling, difficulty in urination, painful urination Proteinuria WBCs and RBCs
  52. 52. Check your urine Urinalysis In the absence of UTI First void Midcatch stream Request for a MICRAL test if routine urinalysis is negative
  53. 53. Chronic Kidney Disease and Diabetes In most patients with diabetes, CKD should be attributable to diabetes if: Macroalbuminuria is present; or Microalbuminuria is present In the presence of diabetic retinopathy NKF K/DOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease, AJKD, Vol 49, No 2, Supplement 2, February 2007
  54. 54. Delaying Progression of DKD to CKD
  55. 55. Delaying Progression of DKD to CKD A ACE- inhibitors/ ARBs
  56. 56. Delaying Progression of DKD to CKD A B ACE- Blood inhibitors/ Pressure ARBs
  57. 57. Delaying Progression of DKD to CKD A B C ACE- Blood Cholesterol inhibitors/ Pressure ARBs
  58. 58. Delaying Progression of DKD to CKD A B C D ACE- Blood Cholesterol Diet inhibitors/ Pressure ARBs
  59. 59. Delaying Progression of DKD to CKD A B C D ACE- Blood Cholesterol Diet inhibitors/ Pressure ARBs E Educate
  60. 60. Delaying Progression of DKD to CKD A B C D ACE- Blood Cholesterol Diet inhibitors/ Pressure ARBs E F Educate Fasting blood sugar
  61. 61. Delaying Progression of DKD to CKD A B C D ACE- Blood Cholesterol Diet inhibitors/ Pressure ARBs E F G Educate Fasting Glass of blood sugar water
  62. 62. Delaying Progression of DKD to CKD A B C D ACE- Blood Cholesterol Diet inhibitors/ Pressure ARBs E F G H Educate Fasting Glass of Hemoglobin blood sugar water
  63. 63. Delaying Progression U of DKD to CKD Urine A B C D ACE- Blood Cholesterol Diet inhibitors/ Pressure ARBs E F G H Educate Fasting Glass of Hemoglobin blood sugar water
  64. 64. Thank You http://www.sagipbuhay.org

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