Diabetic+Nephropathy

1. Diabetic Nephropathy

2. Diabetic Nephropathy
aOver 40% of new cases of end-stage
renal disease (ESRD) are attributed to
diabetes.
SIn 2001, 41,312 people with diabetes
began treatment for end-stage renal
disease.
fIn 2001, it cost $22.8 billion in public
and private funds to treat patients
with kidney failure.
uMinorities experience higher than
average rates of nephropathy and
kidney disease
Incidence of ESRD
Resulting from Primary
Diseases (1998)
43%
23%
12%
3%
19%
Diabetes
Hypertension
Glomerulonephritis
Cystic Kidney
Other Causes

3. Five Stages of Kidney Disease
Stage 1: Hyperfiltration, or an increase in
glomerular filtration rate (GFR) occurs.
Kidneys increase in size.
Stage 2: Glomeruli begin to show damage
and microalbuminurea occurs.
Stage 3: Albumin excretion rate (AER)
exceeds 200 micrograms/minute, and blood
levels of creatinine and urea-nitrogen rise.
Blood pressure may rise during this stage.

4. Five Stages of Kidney Disease
(con’t.)
Stage 4: GFR decreases to less than 75 ml/min, large amounts of
protein pass into the urine, and high blood pressure almost always
occurs. Levels of creatinine and urea-nitrogen in the blood rise
further.
Stage 5: Kidney failure, or end stage renal disease (ESRD). GFR is
less than 10 ml/min. The average length of time to progress from
Stage 1 to Stage 4 kidney disease is 17 years for a person with type
1 diabetes. The average length of time to progress to Stage 5,
kidney failure, is 23 years.

5. Screening for Diabetic Nephropathy
Test When Normal Range
Blood
Pressure
1
Each office visit <130/80 mm/Hg
Urinary
Albumin
1
Type 2: Annually
beginning at diagnosis
Type 1: Annually, 5-years
post-diagnosis
<30 mg/day
<20 mg/min
<30 mg/mgcreatinine
1
American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004

6. STAGES OF DIABETIC NEPHROPATHY
Stage of
nephropathy
Urine dipstick
for protein
Urine ACR
(mg/mmol)
24-hour urine
for albumin
Normal Negative < 2.0 men
< 2.8 women
< 30 mg/day
MicroalbuminuriaNegative 2.0 - 20 men
2.8 - 28 women
30 - 300 mg/day
Overt
nephropathy
(macroalbuminuri
a)
Positive > 20 men
> 28 women
> 300 mg/day
Positive > 66.7 men
> 93.3 women
> 1000 mg/day

7. WHEN: Type 1 - annually after puberty and 5 years of DM
Type 2 - at diagnosis and then annually
WHAT: random urine ACR;
and random urine dipstick
Normal
< 2.0 mg/mmol men
< 2.8 mg/mmol women
Rescreen in 1 year Microalbuminuria
2.0 - 20 mg/mmol men
2.8 - 28 mg/mmol women
Macroalbuminuria
> 20 mg/mmol men
> 28 mg/mmol women
Diabetic nephropathy diagnosed
Up to 2 repeat random urine ACRs performed 1
week to 2 months apart
Suspicion of nondiabetic
renal disease?
Yes
Workup or referral for
nondiabetic renal diseaseNo
Check ACR results
Only 1 abnormal ACR: Repeat
screen in 1 year
Any 2 abnormal out of 3 ACRs:
Diabetic nephropathy diagnosed
SCREENING FOR NEPHROPATHY

8. Priorities for vascular and renal protection
Clinical Issue Target Population Interventions
Vascular
protection
All people w/DM ACE inhibitor, ASA, BP
control, glycemic control,
lifestyle modification, lipid
control, smoking cessation
Elevated BP All people w/DM with
hypertension (regardless of
whether nephropathy is
present)
Rx according to
hypertension guidelines
Renal protectionAll people w/DM with
nephropathy (even in the
absence of hypertension)
Rx according to
nephropathy guidelines

9. Treatment of Diabetic Nephropathy
•Hypertension Control - Goal: lower blood pressure to
<130/80 mmHg
–Antihypertensive agents
•Angiotensin-converting enzyme (ACE) inhibitors
–captopril, enalapril, lisinopril, benazepril, fosinopril, ramipril,
quinapril, perindopril, trandolapril, moexipril
•Angiotensin receptor blocker (ARB) therapy
–candesartan cilexetil, irbesartan, losartan potassium,
telmisartan, valsartan, esprosartan
•Beta-blockers

10. •Glycemic Control
–Preprandial plasma glucose 90-130 mg/dl
–A1C <7.0%
–Peak postprandial plasma glucose <180 mg/dl
–Self-monitoring of blood glucose (SMBG)
–Medical Nutrition Therapy
•Restrict dietary protein to RDA of 0.8 g/kg
body weight per day
Treatment of Diabetic Nephropathy
(cont.)

11. Treatment of End-Stage Renal Disease
(ESRD)
There are three primary treatment options for
individuals who experience ESRD:
1. Hemodialysis
2. Peritoneal Dialysis
3. Kidney Transplantation

12. Hemodialysis
•Procedure
–A fistula or graft is created to access the
bloodstream
–Wastes, excess water, and salt are removed from
blood using a dialyzer
–Hemodialysis required approx. 3 times per week,
each treatment lasting 3-5 hrs
–Can be performed at a medical facility or at home
with appropriate patient training

13. •Hemodialysis Diet
–Monitor protein intake
–Limit potassium intake
–Limit fluid intake
–Avoid salt
–Limit phosphorus intake
•Complications
–Infection at access site
–Clotting, poor blood flow
–Hypotension
Hemodialysis (cont.)

14. Peritoneal Dialysis
•Procedure
–Dialysis solution is transported into the abdomen through a
permanent catheter where it draws wastes and excess water
from peritoneal blood vessels. The solution is then drained
from the abdomen.
–Three Types of Peritoneal Dialysis
•Continuous Ambulatory Peritoneal Dialysis (CAPD)
•Continuous Cycler-Assisted Peritoneal Dialysis (CCPD)
•Combination CAPD and CCPD

15. Peritoneal Dialysis (cont.)
•Peritoneal Dialysis Diet
–Limit salt and fluid intake
–Consume more protein
–Some potassium restrictions
–Reduce caloric intake
•Complications
–Peritonitis

16. Kidney Transplant
•Procedure
–A cadaveric kidney or kidney from a related or non-
related living donor is surgically placed into the
lower abdomen.
–Three factors must be taken into consideration to
determine kidney/recipient match:
•Blood type
•Human leukocyte antigens (HLAs)
•Cross-matching antigens

17. Kidney Transplant (cont.)
•Kidney Transplant Diet
–Reduce caloric intake
–Reduce salt intake
•Complications/Risk Factors
–Rejection
–Immunosuppressant side effects
•Benefits
–No need for dialysis
–fewer dietary restrictions
–higher chance of living longer

18. How Can You Prevent Diabetic Kidney
Disease?
•Maintain blood pressure <130/80 mm/Hg
•Maintain preprandial plasma glucose
90-130 mg/dl
•Maintain postprandial plasma glucose
<180 mg/dl
•Maintain A1C <7.0%

19. References
American Diabetes Association: Nephropathy in Diabetes (Position
Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004
National Kidney and Urologic Diseases Information Clearinghouse.
Kidney Disease of Diabetes. Bethesda, MD: National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes of
Health (NIH), DHHS; 2003.
United States Renal Data System. USRDS 2003 Annual Data
Report. Bethesda, MD: National Institute of Diabetes and Digestive
and Kidney Diseases, National Institutes of Health (NIH), DHHS;
2003.
DeFronzo RA: Diabetic nephropathy: etiologic and therapeutic
considerations. Diabetes Reviews 3:510-547, 1995
National Kidney and Urologic Diseases Information Clearinghouse.
Kidney Failure: Choosing a Treatment That’s Right For You.
Bethesda, MD: National Institute of Diabetes and Digestive and
Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003.

20. THANK YOU