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Diabetic Kidney Disease
- 1. Diabetic Kidney Disease Dr.Sanjay Maitra MD,DM(PGI,Chd),Clin.Fellowship Toronto Univ. Sr.Consultant Nephrologist Apollo Health City, Hyderabad
- 2. Outline of Talk What is Diabetic Kidney Disease? Why do we need to know about Diabetic Kidney Disease? Who are prone to get Diabetic Kidney Disease? What are the signs and symptoms of Diabetic Kidney Disease How do you diagnose Diabetic Kidney Disease? How does one manage Diabetic Kidney Disease? Newer drugs which are promising in the treatment of Diabetic Kidney Disease Summary
- 8. How to Diagnose Diabetes HbA1c > 6.5 Fasting Blood Sugar > 126mg/dl 2 hrs PLBS >200mg/dl
- 9. HOW TO TREAT DIABETES
- 10. Diabetes: A global emergency Diabetes is likely the 5th leading cause of death worldwide
- 11. 2014 2035 WORLD 387 million WORLD 592 million people living with diabetes Middle East and North Africa 85% South East Asia 64% South and Central America 55% Western Pacific 46% North America and Caribbean 30% Europe 33% Africa 93% 53%
- 12. These are all Lifestyle Related Diseases Life style Related Diseases are just a subset of NCD’s
- 15. What is Diabetic Nephropathy? It is one of the long term microvascular complications of Diabetes It is a clinical syndrome characterized : Persistent albuminuria (>300 mg/d or >200 μg/min) that is confirmed on at least 2 occasions 3-6 months apart Progressive decline in the glomerular filtration rate (GFR) Elevated arterial blood pressure Present in patients with Worse glycaemic control Hypertension Glomerular Hyperfiltration Genetic Predisposition
- 16. 35-40 % of Diabetics ultimately have involvement of Kidneys Diabetic Kidney Disease The leading cause of Kidney failure in adults
- 18. Cross sectional study involving 52,273 patients Mean age 50.1±14.6 yrs M:F ratio 70:30 Diabetic nephropathy –commonest cause of CKD (31%) CKD of unknown aetiology (16%) CGN (14%) Hypertensive nephrosclerosis (13%)
- 19. Monthly Cost Of haemodialysis at 3 HD/wk Rs 12,000- Rs 30,000 Monthly cost Of Erythropoeitin per month Rs 7,000-Rs 10,000 Monthly cost of CAPD 3 exchanges per day Rs. 20,000-Rs 25,000 Cost of transplant procedure Rs 3,00,000- Rs, 7,00,000 Cost of immunosuppressive medicines (Using Tacrolimus,MMF and steroids) Rs 10,000-Rs 15,000 per month Approx.cost of Renal replacement therapy in India
- 22. CKD- a continuum Stages of CKD –KDIGO 2012
- 24. Complications increase as CKD progresses Stage V Kidney Failure ESRD Stage IV Severe Kidney Function Stage III Moderate Kidney Function Stage II Mild Kidney Function Stage I CKD Risk Factors/Damage with preserved GFR 130 120 110 100 90 80 70 60 50 40 30 20 15 10 0 Kidney Function - Glomerular Filtration Rate (ml/min/1.73m2 ) MI, CHF, CV Death
- 25. Who are at Risk of progression in Diabetic nephropathy?
- 26. Risk factors for Diabetic Kidney Disease Non-Modiable Genetic Factors Male gender Diabetes onset at 5-15 yrs Long duration of Diabetes Increasing age (>65 yrs) Family history of DKD Modifiable Poor blood sugar control Poor Blood pressure control Poor lipid control Smoking Metabolic Syndrome Insulin Resistance Sedentary Lifestyle Increased salt intake
- 27. Symptoms and Signs of Diabetic Kidney Disease Early stages Swelling of feet and later the body Worsening shortness of breath Anaemia Poor Blood pressure control Later stages(when kidney failure sets in) Lack of appetite, nausea ,vomiting Severe breathlessness Severe anaemia Itching and bone pains Bleeding and unconsciousness in late stages
- 28. Diabetic Kidney Disease Very often missed
- 29. Diabetic Kidney Disease-Very often missed Non-specific symptoms of renal failure Mild edema and blood pressures ignored Poor awareness of renal disease in community nd physicians
- 30. How do you diagnose diabetic kidney disease?
- 33. What are the minimum investigations needed to diagnose Diabetic Kidney Disease Check S.Creatinine Blood urea is not as good Check for protein in the urine Check the patients Blood Pressure It is expected to be high
- 35. Effect of protein restriction in diabetic nephropathy These results were not replicated in a later trial. May cause malnutrition
- 36. Current treatment regimens for treating Diabetic kidney disease Strict Glycaemic Control ACE Inhibitors/ARB for BP control Primary prevention Proteinuria reduction Preservation of renal functions Mineralocorticoid Receptor antagonists Endothelin antagonists Role of Diltiazem and verapamil Cholesterol control Lifestyle modification-Weight reduction/Smoking Diet –Sodium and protein restriction
- 38. Are Current therapies enough? Possibly not Key pathogenetic mechanisms leading to progression are not inactivated Several high profile trials have failed suggesting insufficient understanding of pathogenetic pathways Present rates of progression to ESRD are unacceptable , there will be an explosion in the numbers if we do not act fast Current trials looking at Protenuria reduction as a sole marker of drug efficacy may be faulty Inadequate knowledge of the exact patho-physiology of Diabetic Kidney disease is lacking –hampering drug development
- 39. Newer therapies which are being tried out
- 40. Therapies which hold promise Newer antidiabetic agents SGLT-2 inhibitors :The Gliflozins,e.g Empagliflozin GLP-1 agonists : Liraglutide DPP4 inhibitors: Linagliptin, Sitagliptin Aldosterone Inhibitors Spironolactone,Eplerenone Xanthine Oxidase Inhibitors Allopurinol, Febuxostat Phosphodiesterase inhibitors Pentoxyfilline
- 41. How can any common man prevent the progression of Diabetic Kidney Disease
- 42. How can any one prevent the progression of Diabetic Kidney Disease From the patients stand lifestyle modification is the key Regular physical exercise Balanced Nutrituous Diet, high fibre ,Low fat, Low Salt, Recommended amounts of Protein Stop Smoking Good Glycaemic control (HbA1c <7) Proper Blood Pressure control (BP <130/80 mm of Hg) Keep lipids under check Avoid any Nephrotoxic drug intake Pain-killers, Some antibiotics, indigenous medicines Be aware of any infective focus in the body Visit your doctor periodically and follow his instructions
- 43. Treatment Options For Irreversible Severe Renal failure (ESRD) Dialysis Haemodialysis Peritoneal Dialysis
- 44. Treatment Options For Irreversible Severe Renal failure (ESRD) Kidney Transplantation Living Cadaveric
- 45. Summary Diabetic Kidney Disease is a common problem in long standing Diabetics It is preferable to identify the problem early and try to control its progression If not managed properly patients end up in ESRD and/or severe CAD Multifactorial approach to treatment shows benefits but is not fool-proof Newer modalities are being constantly tried to deal with this menace
- 46. THANK YOU
Editor's Notes
- mmm
- CKD Population 5-100x more likely to die than develop ESRD CVD is 2x as common and advances at 2x the rate of CKD Premature CHD Death is Major issue for CKD patient Chronic Renal Insufficiency is a Cardiovascular Risk Equivalent National Kidney Foundation 1999 American Heart Association 2001
- Background Intensified multifactorial intervention — with tight glucose regulation and the use of renin–angiotensin system blockers, aspirin, and lipid-lowering agents — has been shown to reduce the risk of nonfatal cardiovascular disease among patients with type 2 diabetes mellitus and microalbuminuria. We evaluated whether this approach would have an effect on the rates of death from any cause and from cardiovascular causes. Methods In the Steno-2 Study, we randomly assigned 160 patients with type 2 diabetes and persistent microalbuminuria to receive either intensive therapy or conventional therapy; the mean treatment period was 7.8 years. Patients were subsequently followed observationally for a mean of 5.5 years, until December 31, 2006. The primary end point at 13.3 years of follow-up was the time to death from any cause. Results Twenty-four patients in the intensive-therapy group died, as compared with 40 in the conventional-therapy group (hazard ratio, 0.54; 95% confidence interval [CI], 0.32 to 0.89; P = 0.02). Intensive therapy was associated with a lower risk of death from cardiovascular causes (hazard ratio, 0.43; 95% CI, 0.19 to 0.94; P = 0.04) and of cardiovascular events (hazard ratio, 0.41; 95% CI, 0.25 to 0.67; P<0.001). One patient in the intensive-therapy group had progression to end-stage renal disease, as compared with six patients in the conventional-therapy group (P = 0.04). Fewer patients in the intensive-therapy group required retinal photocoagulation (relative risk, 0.45; 95% CI, 0.23 to 0.86; P = 0.02). Few major side effects were reported. Conclusions In at-risk patients with type 2 diabetes, intensive intervention with multiple drug combinations and behavior modification had sustained beneficial effects with respect to vascular complications and on rates of death from any cause and from cardiovascular causes. (ClinicalTrials.gov number, NCT00320008.)