This document summarizes diabetic kidney disease (DKD), the leading cause of end-stage renal disease in the United States. DKD risk factors include age, sex, race, family history, hypertension, and poor glycemic control. Intensive glucose and blood pressure control can delay DKD progression. While current therapies can slow DKD, innovation is still needed to improve outcomes given residual risks. Novel drug classes targeting DKD mechanisms may provide future treatment options.
Slidedeck of the presentation I gave during the East by Southwest conference, co-organized by the Division of Nephrology (UNM) and the Renal and Electrolyte Division (UPMC)
ABSTRACT- Background: Viral hepatitis B and C can lead to the end stage liver disease and diabetes mellitus is also
a life-long chronic disease. Simultaneous presences of both of these conditions lead to synergistic detrimental outcome.
So identification of diabetes mellitus at the initial evaluation of a patient having chronic hepatitis B and C is essential.
Materials and methods: This study was designed as a retrospective single center cross-sectional study. The association
of viral hepatitis B and C with diabetes mellitus was investigated at the Liver Centre Dhaka, Bangladesh for a period of
12 years. HBsAg was tested for hepatitis B virus infection and anti-HCV for hepatitis C virus infection. Demographic
profile and biochemical data were retrieved from records.
Results: A total of 29425 cases were analyzed in the study [median age 31(19–95) years, 24615(84%) males]. HBsAg
positive were 27475 and hepatitis C were 1950. Patients with hepatitis C were older than hepatitis B (p<0.001).
Although previous history of jaundice was similar in both infections but history of blood transfusion was more common
among hepatitis C patients (p<0.001). Analyzing different conditions of liver disease, it was observed that hepatitis B
virus infection was highly responsible for acute hepatitis than hepatitis C (10.7% vs 1.1%) (p<0.001). Chronic hepatitis
was similar in rate (73.3% vs 59.9%). But in both conditions of cirrhosis of liver like compensated and decompensated
states, hepatitis C virus was significantly responsible than the hepatitis B virus 24.7% vs 9.6% (p<0.001) and 14.3% vs
6.4% (p<0.001) respectively. The most significant finding was very higher rate of diabetes among hepatitis C which
was 22.6% while only 1.8% among hepatitis B virus infection (p<0.001).
Conclusion: Hepatitis C virus was highly related with the presence of diabetes than hepatitis B.
Key-words- Diabetes mellitus, Prevalence, Hepatitis B virus, Hepatitis C virus
Slidedeck of the presentation I gave during the East by Southwest conference, co-organized by the Division of Nephrology (UNM) and the Renal and Electrolyte Division (UPMC)
ABSTRACT- Background: Viral hepatitis B and C can lead to the end stage liver disease and diabetes mellitus is also
a life-long chronic disease. Simultaneous presences of both of these conditions lead to synergistic detrimental outcome.
So identification of diabetes mellitus at the initial evaluation of a patient having chronic hepatitis B and C is essential.
Materials and methods: This study was designed as a retrospective single center cross-sectional study. The association
of viral hepatitis B and C with diabetes mellitus was investigated at the Liver Centre Dhaka, Bangladesh for a period of
12 years. HBsAg was tested for hepatitis B virus infection and anti-HCV for hepatitis C virus infection. Demographic
profile and biochemical data were retrieved from records.
Results: A total of 29425 cases were analyzed in the study [median age 31(19–95) years, 24615(84%) males]. HBsAg
positive were 27475 and hepatitis C were 1950. Patients with hepatitis C were older than hepatitis B (p<0.001).
Although previous history of jaundice was similar in both infections but history of blood transfusion was more common
among hepatitis C patients (p<0.001). Analyzing different conditions of liver disease, it was observed that hepatitis B
virus infection was highly responsible for acute hepatitis than hepatitis C (10.7% vs 1.1%) (p<0.001). Chronic hepatitis
was similar in rate (73.3% vs 59.9%). But in both conditions of cirrhosis of liver like compensated and decompensated
states, hepatitis C virus was significantly responsible than the hepatitis B virus 24.7% vs 9.6% (p<0.001) and 14.3% vs
6.4% (p<0.001) respectively. The most significant finding was very higher rate of diabetes among hepatitis C which
was 22.6% while only 1.8% among hepatitis B virus infection (p<0.001).
Conclusion: Hepatitis C virus was highly related with the presence of diabetes than hepatitis B.
Key-words- Diabetes mellitus, Prevalence, Hepatitis B virus, Hepatitis C virus
New Therapeutics in Diabetic Kidney Disease
Conjoint Meeting of the Iraqi Society of Nephrology and Renal Transplantation and The Iraqi Diabetes Association.
How to link glucose control to cv outcomesYichi Chen
Outline
1.CV risk of DM patient
2.Glucose to CV outcome - Intensive control vs Conventional control
3.Hypoglycemia
4.Different drugs, different outcomes
5.Expect to Future
Journal Club about the Phase 2 study of Selonsertib in Diabetic Kidney Disease to Our Division on 12/9/19.
Also an intro about the Phase 3 study (MOSAIC) we will be launching before the end of the year
New Therapeutics in Diabetic Kidney Disease
Conjoint Meeting of the Iraqi Society of Nephrology and Renal Transplantation and The Iraqi Diabetes Association.
How to link glucose control to cv outcomesYichi Chen
Outline
1.CV risk of DM patient
2.Glucose to CV outcome - Intensive control vs Conventional control
3.Hypoglycemia
4.Different drugs, different outcomes
5.Expect to Future
Journal Club about the Phase 2 study of Selonsertib in Diabetic Kidney Disease to Our Division on 12/9/19.
Also an intro about the Phase 3 study (MOSAIC) we will be launching before the end of the year
Diabetic nephropathy is a clinical syndrome characterized by the following :
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.
Three major histologic changes occur in the glomeruli of persons with diabetic nephropathy:
First, mesangial expansion is directly induced by hyperglycemia, perhaps via increased matrix production or glycation of matrix proteins.
Second, thickening of the glomerular basement membrane (GBM) occurs.
Third, glomerular sclerosis caused by intraglomerular hypertension (induced by dilatation of the afferent renal artery or from ischemic injury induced by hyaline narrowing of the vessels supplying the glomeruli).
These different histologic patterns appear to have similar prognostic significance.
Several issues are key in the medical care of patients with diabetic nephropathy.
These include glycemic control, management of hypertension, and reducing dietary salt intake and phosphorus and potassium restriction in advanced cases.
A meta-analysis from the Cochrane Database shows a large fall in blood pressure with salt restriction, similar to that of single-drug therapy
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
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Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
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2. Intro
★ DKD leading cause ESRD in US
★ 30% in T1 DM and 40 % T2 DM
★ All cause and cardiovascular mortalitility is majorly attributable to DKD
3. RISK FACTORS
SUSCEPTIBILTY FACTORS
-Age (elderly)
-sex (male)
-race/ethnicity (black,
american indian, hispanic,
asian pacific islanders)
-family history
❖ INITIATION FACTORS
-Hyperglycemia
-AKI
- genetic kidney disease
-smoking
PROGRESSION FACTOR
-HTN
-Dietery factors (high protein diet)
-Obesity
4. HYPERGLYCEMI
A
DCCT TRIAL
In patients with DM1, an intensive glucose control intervention Targeting a hemoglobin A1C (HbA1C)
level <7% reduced the 9-year risks of developing microalbuminuria and macroalbuminuria by 34% and
56%, respectively, compared with standard care .After a median follow-up of 22 years, the intensive
therapy group had approximately 50% lower risk of a low eGFR (,60 ml/min per 1.73 m2), and the average
rate of eGFR loss was significantly reduced from 1.56 ml/min per 1.73 m2 per year with standard therapy
to 1.27 ml/min per 1.73 m2 per year with intensive therapy
Similarly, in patients with newly diagnosed DM2, 10 years of an intensive glycemic control intervention
targeting an HbA1C of 7% produced a 24% reduction in development of microvascular complications,
including DKD, compared with conventional therapy . After 12 years, intensive glycemic control resulted
in a 33% reduction in the risk of development of microproteinuria or “clinical grade” proteinuria
and a significant reduction in the proportion of patients with a doubling of the blood creatinine level
(0.9% versus 3.5%) relative to the conventional therapy group
5.
6. UKPDS TRIAL
● Nephropathy, retinopathy and possibly neuropathy benefited by lowering blood glucose in
type 2 DM with intensive therapy( hba1c <7%) compared with conventional therapy (Hba1c
<7.9%)
● Overaall microvascular complications decreased by 25 %
7. ● In patients with newly diagnosed DM2, treating to a target BP 150/85 mmHg over a median of 15
years resulted in a significant 37% risk reduction of microvascular complications compared with that
in patients treated to a target of ,180/105 mmHg.
● Each 10-mmHg increase in mean systolic BP was associated with a 15% increase in the hazard ratio
for development of both micro- and macroalbuminuria and impaired kidney function
● Baseline systolic BP .140 mmHg in patients with DM2 has been associated with higher risk of ESRD
and death
HYPERTENSION
11. ● UKPDS -Of enrolled patients, approximately 2% per year progressed from normo- to
microalbuminuria and from micro- to macroalbuminuria.
● At a median of 15 years after diagnosis, 40% of participants developed albuminuria, and 30%
developed eGFR,60 ml/min per 1.73 m2 or doubling of the blood creatinine level .
● 60% of those developing kidney functional impairment did not have preceding albuminuria, and 40%
never developed albuminuria during the study .
Albuminuria is a dynamic, fluctuating condition rather than a linearly
progressive process
13. A recent autopsy study
● Higher prevalence of DKD diagnosed histologically compared with that
indicated by clinical laboratory testing.
● Of 168 patients with DM1 or DM2, 106 exhibited histopathologic
changes characteristic of DKD.
● Albuminuria or low eGFR was absent in 20% (20 of 106) of patients
throughout life
14. ● Renal structure changes in patients with DM2 are similar to those seen in DM1,
● Early renal pathology studies described a high prevalence of nondiabetic
glomerular disease in the patients with DM2 population, probably because of
selection bias: patients who were diabetic and underwent biopsies tended to
have atypical presentations of DKD.
● Conclusions from more recent biopsy studies are more conservative, estimating
,10% prevalence of non-DKD in patients with diabetes and albuminuria
15. FACTORS AFFECTING VARIED PRESENTATION OF DKD IN T2DM
● Unreliable timing of onset
● Longer exposure of hyperglycemia
● Older population
● Atherosclerosis
● t/t with RAAS inhibitors
24. DIAGNOSIS OF DKD
● DKD is identified clinically by persistently high urinary albumin-to-creatinine ratio
>30 mg/g and/or sustained reduction in eGFR below 60 ml/min per 1.73 m2.
● Screening performed annually for patients with DM1 beginning 5 years after
diagnosis and annually for all patients with DM2 beginning at the time of diagnosis.
● In patients with albuminuria, the presence of diabetic retinopathy is strongly
suggestive of DKD.
● The preferred test- urinary albumin-to-creatinine ratio performed on a spot sample,
preferably in the morning .
● The eGFR is calculated from the serum creatinine concentration.
● Chronic Kidney Disease-Epidemiologic Prognosis Initiative equation is more accurate,
particularly at eGFR levels in the normal or near-normal range, the Modification of
Diet in Renal Disease equation is typically reported by clinical laboratories
● Confirmation of albuminuria or low eGFR requires two abnormal measurements at least
3 months apart. If features atypical of DKD
25. DKD unlikely if -
● sudden onset of low eGFR or rapidly decreasing eGFR
● Abrupt increase in albuminuria
● Development of nephrotic or nephritic syndrome
● Refractory hypertension
● Signs or symptoms of another systemic disease
● 30% eGFR decline within 2–3 months of initiation of a renin-
angiotensin system inhibitor
26. ● Anemia and bone and mineral metabolism disorders develop earlier in DKD
than in other types of CKD.
● Nearly twice as likely to have anemia compared with patients with
nondiabetic CKD and comparable eGFR (predom. Tubulointerstitial ds---decr
EPO).
● Insulin is a cofactor for parathyroid hormone release--insulin deficiency
and/or resistance associated with lower PTH --- predispose patients with
DKD to adynamic bone disease
DKD vs CKD of other causes
27. GLUCOSE CONTROL
● Intensive glucose control after onset of complications or in
longstanding diabetes does not reduce risk of DKD progression or
improve overall clinical outcomes.
● Targeting low HbA1C (6%–6.9%) compared with standard therapy
increased the risk of severe hypoglycemia
● An analysis of patients with DM2 and early-stage CKD showed 30%
and 40% higher risks for all cause mortality and CV mortality,
respectively, with intensive glycemic control compared with standard
therapy.
TREATMENT
28. Conclusion-
● ADA - targets for glycemia tailored to age, comorbidities, and life
expectancy ( More stringent goals, such as HbA1C,6.5%, may be reasonable
for patients with shorter duration of diabetes, younger age, absence of
complications, and a longer life expectancy. To the contrary, less stringent
goals of HbA1C,8% recommended for longstanding diabetes, older age,
micro- and macrovascular complications, and limited life expectancy
● National Kidney Foundation–Kidney Disease Outcomes Quality Initiative
and KDIGO- target HbA1c of about 7.0% except in patients at risk for
hypoglycemia, such as those with diabetes and CKD.
29. HYPERTENSION
● JNC-8 initiation of pharmacologic treatment at a systolic BP >140 mmHg or
diastolic BP >90 mmHg, with treatment goals less than these levels.
● Initial antihypertensive treatment - thiazide-type diuretic, a calcium channel
blocker, an angiotensin-converting enzyme (ACE) inhibitor, or an angiotensin
receptor blocker (ARB).
● In black patients with diabetes, the JNC-8 recommends initial treatment with
a thiazide diuretic or calcium channel blocker.
● In patients who are diabetic with high levels of albuminuria, the medication
regimen should include an ACE inhibitor or an ARB alone or in combination with
medication from another drug class.
● KDIGO guidelines recommend use of an ACE or an ARB and a BP goal ,130/80
mmHg in all patients with CKD and albuminuria irrespective of diabetes status
30. NOVEL THERAPIES
Ruboxistaurin
❏ protein kinase C-b inhibito
❏ tuttle et al
❏ Outcome- decreased albuminuria and stabilized renal fn
Baricitinib
❏ selective Janus kinase 1 and Janus kinase 2 inhibitor
❏ Study to test safety and efficacy of Baricitinib
❏ Outcome- decreased albuminuria but no effect on eGFR
Pentoxifylline
❏ anti-inflammatory and antifibrotic agent
❏ PREDIAN
❏ Outcome- eGFR declined 4.3 ml/min/1.73 m2 less than control
31. Atrasentan
❏ selective endothelin A receptor antagonist
❏ RADAR ,outcome- 35 % reduction in albuminuria
❏ SONAR, outcome-still ongoing
Finerenone
❏ Steroid mineralocorticoid receptor antagonist
❏ ARTS-DN
❏ Outcome- no diff. in eGFR but 17-40 % red in albuminuria
Allopurinol
❏ Xanthine oxidase inhibitor
❏ PERL
❏ ongoing
32. AVOR-TIMI
❏ Saxagliptin (DPP-4 inhibitor)
❏ Improvement in and/or less deterioration in ACR categories; no changes in eGFR
CARMELINA
❏ Linagliptin (DPP-4 inhibitor)
❏ Better glycemic control in DKD pt and no increased CV risk
LEADER
❏ Liraglutide (GLP-1 receptor agonist)
❏ Lower incidence of nephropathy (newonset albuminuria, doubling of SCr and CrCl,45 ml/min per 1.73
m2; need for RRT, death to renal causes
AWARD-7
❏ Dulaglutide (GLP-1 receptor agonist)
❏ estimated completion in July of 2018
EMPA-REG OUTCOME
❏ Empaglifozin (SGLT-2 inhibitor)
❏ Relative risk reduction of doubling of SCr (1.5% versus 2.6%); 38% relative risk reduction of progression
to macroalbuminuria (11.2% versus 16.2%); 55% relative risk reduction of initiation of RRT (0.3% versus
0.6%); slowing GFR decline (annual decrease 0.1960.11 versus 1.6760.13 ml/min per 1.73 m2
CREDENCE
❏ Canaglifozin (SGLT-2 inhibitor)
❏ In progress, estimated completion in June of 2019
33. ❏ Despite current therapies, there is large residual risk of diabetic
kidney disease onset and progression.
❏ Widespread innovation is urgently needed to improve health
outcomes for patients with diabetic kidney disease.
❏ Achieving this goal will require characterization of new biomarkers,
designing clinical trials that evaluate clinically pertinent end points,
and development of therapeutic agents targeting kidney-specific
disease mechanisms (e.g., glomerular hyperfiltration, inflammation,
and fibrosis).
Conclusion