Diabetic Nephropathy

Diabetic Nephropathy

Kidney disease is common in people affected by diabetes mellitus

Definition Urinary albumin excretion of more than 300mg in a 24 hour collection or macroalbuminuria Abnormal renal function, an increase in creatinine or decrease in creatinine clearance or egfr

Natural History of Disease Diabetic nephropathy is a disease that progresses gradually over many years. 50 % of type 1 diabetics with overt nephropathy will progress to ESRD within 10 years 20% of type 2 diabetics with overt nephropathy progress to ESRD within 20 years

Chronic Diabetic Nephropathy Progressive increase in proteinuria and decline in renal function, hypertension and high risk of cardiovascular disease

Progression of Renal Disease Microalbuminuria Proteinuria CV Events Death Doubling of Serum Creatinine Levels End-Stage Renal Disease

End Stage Renal Disease Diabetes is the primary cause of ESRD in the US 44% of new ESRD patients are diabetics in the US The incidence of type II DM is increasing the US and around the world

20.8 Million people in the US (7%) have diabetes 13% of African Americans, 9.5% of Hispanics and 15% of Native Americans have diabetes, predominantly type 2 Approximately 20 to 30% of all diabetics will develop evidence of kidney disease

Changes in the Prevalence of CKD* 1420+ (1,687) 1230 to <1420 949 to <1230 824 to <949 Below 824 (748) 1420+ (1632) 1230 to <1420 949 to <1230 824 to <949 Below 824 (779)

Increasing Incidence of Chronic Kidney Disease Primary Diagnosis for Patients Who Start Dialysis Number of Dialysis Patients 700 600 500 400 300 200 100 0 Diabetes 50% Other 10% Glomerulonephritis 13% 243 524 Hypertension 27% 281 355 520 240 R 2 = 99.8% 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 No. of Patients Projection 95% CI United States Renal Data System. Annual data report. 2000.

Uncontrolled hyperglycemia contributes to changes in the kidney which initiate diabetic nephropathy. Long-standing hyperglycemia is a significant risk factor for developing kidney disease. Proteinuria, a marker of disease, also contributes to further progression of disease The renal renin-angiotensin-aldosterone system is locally activated in the kidney.

Control Blood Pressure!! BP control is imperative in slowing the progression of diabetic nephropathy. Regardless of agent used, lower BP in type II diabetics slows the onset and progression of diabetic nephropathy.

ATII preferentially constricts the efferent arteriole in the glomerulus leading to increased intraglomerular capillary pressure.

Signs and Symptoms Few in early stages of disease Advanced disease Proteinuria High BP Leg swelling Nausea/Vomiting Nocturia Decreased doses needed of diabetes meds

Diagnosis Blood and urine tests measuring BUN, creatinine, proteinuria Ultrasound of kidneys Occaisionally biopsy

Lifestyle Modification Tight glycemic control is imperative to prevent and manage diabetic nephropathy DCCT HgbAIC 7.2 vs. 9.2 decreased 54 % incidence macroalbuminuria (type 1) UKPDS Hgb AIC of 7 vs 7.2 % showed significant decrease in development of disease Pancreatic transplant, reversible changes in kidney

Medications Blood pressure control Slows progression of kidney disease and decreases incidence of cardiovascular events Goal BP is less than 130/80 in all diabetics Goal BP in diabetics with macroalbuminuria is 130-125/80 to 75mmHg

3 or more BP meds needed to achieve BP goals in most studies..

BP Meds Type 1 DM ACEI; ARB alternate Type 2 DM ARB; ACEI alternate Diuretic second-line agent*** Beta Blocker or CCB as third-line agent DM with CHF ACEI followed by BB DM with CAD BB, ACEI, Diuretic

CV Risk Factors Follow cholesterol guidelines-statins Don t smoke Diet and Exercise Aspirin low dose

Dietary Low sodium diet: less than 100 meq/d or 5.8 grams of NaCl Avoid protein shakes, normal dietary protein intake, some doctors restrict protein intake in advanced disease

Avoid Nephrotoxins NSAIDs and excess aspirin Radiographic contrast Stop ACEI or ARB if dehydrated

Secondary Complications of Complications CKD Anemia Renal osteodystrophy, secondary hyperparathyroidism Malnutrition, hypoalbuminemia Metabolic acidosis Atherosclerosis, myocardial infarction LVH, CVD, Hospitalizations Decreased mortality in 1 st year of RRT, Vascular Calcifications Protein malnutrition common, Metabolic syndrome Nutritional deficits and bone disease Highest risk of death