Diabetes and Kidney

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Diabetes and Kidney
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Normal Kidney
Diabetic Kidney
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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
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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.

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Diabetic Nephropathy

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

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Proteinuria
Protein (mg) Albumin (mg)
Normal 30-150 10-30
Micro lt500 lt300
Macro gt500 gt300
Nephrotic range gt3000 No need to check
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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)

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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

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Strict glycemic control prevents microalbuminuria
in type 1
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Hypertension

• BP of lt 130 / 80 is ideal
• Prevents progression of Renal Failure
• ? myocardial hypertrophy
• ACE I / ARBs - drugs of choice
• Use with caution if S.Creatinine gt 3 mg
• Choice depends on comorbid conditions too
• b blocker in CAD

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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.

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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

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Ca - PO4 metabolism

• To be tackled early to prevent secondary
  hyperparathyroidism
• AIM
• Ca 10, PO4 lt 5.5 , Ca X PO4 lt 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

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Anaemia

• May occur when GFR lt 50 almost always present
  when GFR lt 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
• gt 13 in pts with CAD

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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. gt 3 double more frequent dosing

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Options of Renal Replacement Therapies

• Dialysis
• Hemodialysis
• Peritoneal dialysis
• Continuous Ambulatory Peritoneal Dialysis
• Continuous Cyclic Peritoneal Dialysis
• Renal Transplantation
• Simultaneous Pancreas Kidney Transplantation

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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
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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.