diabetes-and-kidney, complications of diabetes

complications of diabetes

1. Diabetes and KidneyDiabetes and Kidney

2. Diabetic Kidney
Normal Kidney

3. This number will increase as the diabetic population is
increasing
Diabetic nephropathyDiabetic nephropathy
Commonest cause of Renal failure Commonest cause of Renal failure
50 % of dialysis patients have DM50 % of dialysis patients have DM
30 % of patients with type 1 & 2 30 % of patients with type 1 & 2
develop renal failuredevelop renal failure

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

5. Diabetic NephropathyDiabetic Nephropathy
Clinical syndrome consisting ofClinical syndrome consisting of
–Protein in urineProtein in urine
–High BPHigh BP
–Decline in renal functionDecline in renal function
If > 25 years elapse - unlikely to develop If > 25 years elapse - unlikely to develop
nephropathy.nephropathy.

6. ProteinuriaProteinuria
Protein (mg)Protein (mg)Albumin (mg)Albumin (mg)
NormalNormal 30-15030-150 10-3010-30
MicroMicro <500<500 <300<300
MacroMacro >500>500 >300>300
Nephrotic rangeNephrotic range>3000>3000 No need to No need to
checkcheck

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

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

9. Strict glycemic control prevents Strict glycemic control prevents
microalbuminuria in type 1microalbuminuria in type 1

10. HypertensionHypertension
BP of < 130 / 80 is idealBP of < 130 / 80 is ideal
–Prevents progression of Renal FailurePrevents progression of Renal Failure
 myocardial hypertrophymyocardial hypertrophy
ACE I / ARBs ACE I / ARBs --drugs of choicedrugs of choice
Use with caution if S.Creatinine > 3 mgUse with caution if S.Creatinine > 3 mg
Choice depends on comorbid conditions Choice depends on comorbid conditions
tootoo
 blocker in CADblocker in CAD

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

12. Fluid managementFluid management
Many diabetics have nephrotic state and severe Many diabetics have nephrotic state and severe
edema and need rigorous salt & fluid restrictionedema and need rigorous salt & fluid restriction
Severe edemaSevere edema --600 - 800 ml / day600 - 800 ml / day
Mild to moderateMild to moderate --equal to UOPequal to UOP
No edemaNo edema --UOP + insensible UOP + insensible
losseslosses

13. Ca - POCa - PO
44 metabolism metabolism
To be tackled early to prevent secondary To be tackled early to prevent secondary
hyperparathyroidismhyperparathyroidism
AIMAIM
–Ca ~ 10, POCa ~ 10, PO
44 < 5.5 , Ca X PO < 5.5 , Ca X PO
4 4 < 55< 55
–Ca supplementation 1 - 1.5 gm / dayCa supplementation 1 - 1.5 gm / day
CaCOCaCO
33 - 40 % elemental Ca - 40 % elemental Ca
Ca acetate 20 % Ca acetate 20 %
Ca with meals will act as POCa with meals will act as PO
44 binder binder
To be given empty stomach for Ca suppl.To be given empty stomach for Ca suppl.
–Vit DVit D
33 0.25 – 1 0.25 – 1 g /dayg /day
If POIf PO
44 very high, to be reduced first very high, to be reduced first

14. AnaemiaAnaemia
May occur when GFR < 50 % & almost always May occur when GFR < 50 % & almost always
present when GFR < 30 %present when GFR < 30 %
Correct deficienciesCorrect deficiencies
–Iron, Folic acid, Vit BIron, Folic acid, Vit B
1212, Pyridoxine, Pyridoxine
Erythropoietin 75 - 150 iu/kg SCErythropoietin 75 - 150 iu/kg SC
–With Iron supplementsWith Iron supplements
–Expensive therapy Rs. 8 - 10, 000 / monthExpensive therapy Rs. 8 - 10, 000 / month
–Hb % maintained at 11 - 12Hb % maintained at 11 - 12
> 13 in pts with CAD> 13 in pts with CAD

15. OthersOthers
Lipid lowering - diet, statinsLipid lowering - diet, statins
Low dose aspirinLow dose aspirin
Avoid nephrotoxic drugs & contrast proceduresAvoid nephrotoxic drugs & contrast procedures
Prevent & treat infections energeticallyPrevent & treat infections energetically
Hepatitis B immunizationHepatitis B immunization
–Early immunization idealEarly immunization ideal
–if Cr. > 3 double & more frequent dosingif Cr. > 3 double & more frequent dosing

16. Options of Renal Replacement Options of Renal Replacement
TherapiesTherapies
Dialysis Dialysis
–HemodialysisHemodialysis
–Peritoneal dialysisPeritoneal dialysis
CContinuous ontinuous AAmbulatory mbulatory PPeritoneal eritoneal DDialysisialysis
CContinuous ontinuous CCyclic yclic PPeritoneal eritoneal DDialysisialysis
Renal TransplantationRenal Transplantation
Simultaneous Pancreas KidneySimultaneous Pancreas Kidney TransplantationTransplantation

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

18. ConclusionConclusion
Pathogenesis and progression of Renal Pathogenesis and progression of Renal
Disease in Diabetics is multifactorial and Disease in Diabetics is multifactorial and
intervention should be multi-pronged intervention should be multi-pronged
Glycemic controlGlycemic control
Hypertension controlHypertension control
Treat dyslipdemiaTreat dyslipdemia
OthersOthers
–Diet, Smoking cessation, Exercise etc.Diet, Smoking cessation, Exercise etc.