Diabetes And Kidney

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Information about Diabetes And Kidney

Published on June 22, 2008

Author: arpanbhattacharya

Source: slideshare.net

Diabetes and Kidney

Diabetic Kidney Normal Kidney

Diabetic nephropathy Commonest cause of Renal failure 50 % of dialysis patients have DM 30 % of patients with type 1 & 2 develop renal failure This number will increase as the diabetic population is increasing

Commonest cause of Renal failure

50 % of dialysis patients have DM

30 % of patients with type 1 & 2 develop renal failure

Risk factors for developing Diabetic Nephropathy Poor control of blood glucose, Long duration of Diabetes, Presence of other diabetic complication, Ethnicity (Asian, Pima Indians), Pre-existing High BP, Family h/o of Diabetic Nephropathy, Family h/o Hypertension.

Poor control of blood glucose,

Long duration of Diabetes,

Presence of other diabetic complication,

Ethnicity (Asian, Pima Indians),

Pre-existing High BP,

Family h/o of Diabetic Nephropathy,

Family h/o Hypertension.

Diabetic Nephropathy Clinical syndrome consisting of Protein in urine High BP Decline in renal function If > 25 years elapse - unlikely to develop nephropathy.

Clinical syndrome consisting of

Protein in urine

High BP

Decline in renal function

If > 25 years elapse - unlikely to develop nephropathy.

Proteinuria No need to check >3000 Nephrotic range >300 >500 Macro <300 <500 Micro 10-30 30-150 Normal Albumin (mg) Protein (mg)

Microalbuminuria Called micro… because it is not detectable by normal urine dip stick Urinary albumin (30 - 300 mg/day) Becomes irreversible when reaches 300 Detected by newer generation dipstix (micral)

Called micro… because it is not detectable by normal urine dip stick

Urinary albumin (30 - 300 mg/day)

Becomes irreversible when reaches 300

Detected by newer generation dipstix (micral)

Screening for microalbuminuria Whom to screen Type 1 DM, from 5 years from diagnosis, Annually from diagnosis Abnormal tests Exclude recent vigourous exercise, fever, heart failure, urine infection, Prostatitis and menstruation, Confirm observation twice, Look for hypertension

Whom to screen

Type 1 DM, from 5 years from diagnosis,

Annually from diagnosis

Abnormal tests

Exclude recent vigourous exercise, fever, heart failure, urine infection, Prostatitis and menstruation,

Confirm observation twice,

Look for hypertension

Strict glycemic control prevents microalbuminuria in type 1

Hypertension BP of < 130 / 80 is ideal Prevents progression of Renal Failure  myocardial hypertrophy ACE I / ARBs - drugs of choice Use with caution if S.Creatinine > 3 mg Choice depends on comorbid conditions too  blocker in CAD

BP of < 130 / 80 is ideal

Prevents progression of Renal Failure

 myocardial hypertrophy

ACE I / ARBs - drugs of choice

Use with caution if S.Creatinine > 3 mg

Choice depends on comorbid conditions too

 blocker in CAD

Diet Calories - 35 K cal / kg Proteins of high quality - 0.8 gm / kg Salt - 4 - 5 gm / day Potassium - 50 - 60 meq/day Lipids 30 % of calorie intake.

Calories - 35 K cal / kg

Proteins of high quality - 0.8 gm / kg

Salt - 4 - 5 gm / day

Potassium - 50 - 60 meq/day

Lipids 30 % of calorie intake.

Fluid management Many diabetics have nephrotic state and severe edema and need rigorous salt & fluid restriction Severe edema - 600 - 800 ml / day Mild to moderate - equal to UOP No edema - UOP + insensible losses

Many diabetics have nephrotic state and severe edema and need rigorous salt & fluid restriction

Severe edema - 600 - 800 ml / day

Mild to moderate - equal to UOP

No edema - UOP + insensible

losses

Ca - PO 4 metabolism To be tackled early to prevent secondary hyperparathyroidism AIM Ca ~ 10, PO 4 < 5.5 , Ca X PO 4 < 55 Ca supplementation 1 - 1.5 gm / day CaCO 3 - 40 % elemental Ca Ca acetate 20 % Ca with meals will act as PO 4 binder To be given empty stomach for Ca suppl. Vit D 3 0.25 – 1  g /day If PO 4 very high, to be reduced first

To be tackled early to prevent secondary hyperparathyroidism

AIM

Ca ~ 10, PO 4 < 5.5 , Ca X PO 4 < 55

Ca supplementation 1 - 1.5 gm / day

CaCO 3 - 40 % elemental Ca

Ca acetate 20 %

Ca with meals will act as PO 4 binder

To be given empty stomach for Ca suppl.

Vit D 3 0.25 – 1  g /day

If PO 4 very high, to be reduced first

Anaemia May occur when GFR < 50 % & almost always present when GFR < 30 % Correct deficiencies Iron, Folic acid, Vit B 12 , Pyridoxine Erythropoietin 75 - 150 iu/kg SC With Iron supplements Expensive therapy Rs. 8 - 10, 000 / month Hb % maintained at 11 - 12 > 13 in pts with CAD

May occur when GFR < 50 % & almost always present when GFR < 30 %

Correct deficiencies

Iron, Folic acid, Vit B 12 , Pyridoxine

Erythropoietin 75 - 150 iu/kg SC

With Iron supplements

Expensive therapy Rs. 8 - 10, 000 / month

Hb % maintained at 11 - 12

> 13 in pts with CAD

Others Lipid lowering - diet, statins Low dose aspirin Avoid nephrotoxic drugs & contrast procedures Prevent & treat infections energetically Hepatitis B immunization Early immunization ideal if Cr. > 3 double & more frequent dosing

Lipid lowering - diet, statins

Low dose aspirin

Avoid nephrotoxic drugs & contrast procedures

Prevent & treat infections energetically

Hepatitis B immunization

Early immunization ideal

if Cr. > 3 double & more frequent dosing

Options of Renal Replacement Therapies Dialysis Hemodialysis Peritoneal dialysis C ontinuous A mbulatory P eritoneal D ialysis C ontinuous C yclic P eritoneal D ialysis Renal Transplantation Simultaneous Pancreas Kidney Transplantation

Dialysis

Hemodialysis

Peritoneal dialysis

C ontinuous A mbulatory P eritoneal D ialysis

C ontinuous C yclic P eritoneal D ialysis

Renal Transplantation

Simultaneous Pancreas Kidney Transplantation

Renal replacement therapy Hemodialysis (HD) - Rs. 12 - 15000 / mo Peritoneal dialysis (PD) - Rs. 20000 / mo Renal Transplantation - 3 - 3.5 Lakhs for first year Not funded by the Government Not covered by insurance Very expensive Hence the real need to prevent diabetic ESRD

Hemodialysis (HD) - Rs. 12 - 15000 / mo

Peritoneal dialysis (PD) - Rs. 20000 / mo

Renal Transplantation - 3 - 3.5 Lakhs for first year

Not funded by the Government

Not covered by insurance

Conclusion Pathogenesis and progression of Renal Disease in Diabetics is multifactorial and intervention should be multi-pronged Glycemic control Hypertension control Treat dyslipdemia Others Diet, Smoking cessation, Exercise etc.

Pathogenesis and progression of Renal Disease in Diabetics is multifactorial and intervention should be multi-pronged

Glycemic control

Hypertension control

Treat dyslipdemia

Others

Diet, Smoking cessation, Exercise etc.

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