Diabetes and Kidney

1. Diabetes and Kidney

2. Normal Kidney Diabetic Kidney

3. 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

4. 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.

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

6. Proteinuria

7. 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)

8. 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

9. Strict glycemic control prevents microalbuminuria in type 1

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. Options of Renal Replacement Therapies • Dialysis • Hemodialysis • Peritoneal dialysis • Continuous Ambulatory Peritoneal Dialysis • Continuous Cyclic Peritoneal Dialysis • Renal Transplantation • Simultaneous Pancreas KidneyTransplantation

17. 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

18. 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.