Diabetes and Kidney
Normal Kidney
Diabetic 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
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.
Diabetic Nephropathy
Clinical syndrome consisting of
– Protein in urine – High BP – Decline in renal function
If > 25 years elapse - unlikely to develop nephropathy.
Proteinuria
Protein (mg) Albumin (mg)
Normal Micro Macro
30-150 <500 >500
10-30 <300 >300 No need to check
Nephrotic range >3000
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)
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
Strict glycemic control prevents microalbuminuria in type 1
30
25 Conventional
Percent of patients
20
Intensive
15
10
5
0 0 1 2 3 4 5 6 7 8 9
Year
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
b 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.
Fluid management
Many diabetics have nephrotic state and severe edema and need rigorous salt & fluid restriction Severe edema Mild to moderate No edema - 600 - 800 ml / day - equal to UOP - UOP + insensible losses
Ca - PO4 metabolism
To be tackled early to prevent secondary hyperparathyroidism AIM
– Ca ~ 10, PO4 < 5.5 , Ca X PO4 < 55 – Ca supplementation 1 - 1.5 gm / day
CaCO3 - 40 % elemental Ca Ca acetate 20 % Ca with meals will act as PO4 binder To be given empty stomach for Ca suppl.
– Vit D3 0.25 – 1 mg /day
If PO4 very high, to be reduced first
Anaemia
May occur when GFR < 50 % & almost always present when GFR < 30 %
Correct deficiencies
– Iron, Folic acid, Vit B12, 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
Options of Renal Replacement Therapies
Dialysis – Hemodialysis – Peritoneal dialysis
Continuous Ambulatory Peritoneal Dialysis Continuous Cyclic Peritoneal Dialysis
Renal Transplantation Simultaneous Pancreas Kidney Transplantation
Renal replacement therapy
Very expensive
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
Hence the real need to prevent diabetic ESRD
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.