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Diabetic nephropathyt

Benyamin S.I Hutagaol

Geriatric Department Sudarso General Hospital Pontianak 2012

OUTLINE
INTRODUCTION EPIDEMIOLOGY RISK FACTORS PATHOPHYSIOLOGY STAGING DIAGNOSIS MANAGEMENT

INTRODUCTION
DN is an important cause of morbidity & mortality & is now among the most common causes of ESRF. It is one of the microvasculer complications of DM

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%

Diabetic Nephropathy
Over 40% of new cases of end-stage renal disease (ESRD) are attributed to diabetes. In 2001, 41,312 people with diabetes began treatment for end-stage renal disease. In 2001, it cost $22.8 billion in public and private funds to treat patients with kidney failure. Minorities experience higher than average rates of nephropathy and kidney disease
Incidence of ESRD Resulting from Primary Diseases (1998)
19% 3% 12%

43%

23%

Diabetes Hypertension Glomerulonephritis Cystic Kidney Other Causes

RISK FACTORS
Poor control of blood glucose Long duration of diabetes Presence of other microvascular complications Ethnicity(e.g.Asian races,Africans,Pima Indians) Pre-existing HTN Family Hx of DN Family Hx of HTN

PATHOPHYSIOLOGY
The earliest fxnal abnormality in the diabetic kidney is renal hypertrophy assoc with a raised GFR As the kidney becomes damaged by diabetes,the affernt arteriole becomes dilated to a greater extent than efferent arteriole. This the intraglomerular filteration pressure further damaging the glomerular capillaries. This IGFP shearing forces locally which are thougth to mesangial cell hypertrophy & secretion of extracellular mesangial matrix material.

PATHOGENESIS
This process eventually glomerular sclerosis. The initial structural lesion in the glomerulus is thickening of the basement membrane.

ALBUMINURIA
The earliest evidence of this is microalbuminuria It is a predictive marker of progression to nephropathy in type 1 DM. Microalbuminuria may,after some years,progress to intermittent albuminuria followed by persistent proteinuria. Light microscopic changes of glomerulosclerosis become manifest;both diffuse & nodular can occur. The nodular is sometimes known as KimmelstielWilson lesion.

ALBUMINURIA
Later the glomerulus is replaced by hyaline material. At the stage of persistent proteinuria the plasma creatinine is normal but the average px is only some 510 yrs from ESRF. Pxs with nephropathy typically show normocromic normocytic anaemia & a raised ESR. HTN is a common development & may damage the kidney further. plasma creatinine is a late feature that inevitably progress to renal failure

ISCHAEMIC LESIONS
Arteriolar lesions,with hypertrophy & hyalinization of the vessels,can occur in patients with DM. The appearances are similar to those of hypertensive disease & lead to ischaemic damage to the kidneys.

INFECTIVE LESIONS
UTI(commoner in women) ascending infection because of bladder stasis(autonomic neuropathy) and becomes more easily established in dameged renal tissue.

STAGING OF DN
Stage 1:Hyperfiltration Stage 2:Basement membrane thickening Stage 3:Microalbuminuria Stage 4:Persistent proteinuria Stage 5:End Stage Renal Failure

DIAGNOSIS
The urine of all diabetic patients should be checked regularly for the presense of protein. Once proteinuria is present,other possible causes for this should be considered,but once thes are excluded a presumptive diagnosis of DN can be made. Microalbuminuria is an important indicator of risk of developing overt DN,although it is also found in other conditions. Most reliable as an indicator of DN within 1st 10yrs of type 1 DM< reliable in pxs with type 2 DM.

DIAGNOSIS
Random urine sample can estimate urinary albumin:creatinine ratio(abnormal values: male>2.5,female >3.5) If possible confirm with an albumin excretion rate(AER) of 20-200g/min(30300mg/24hrs);requires timed collection of urine(overnight or 24 hrs)

DIAGNOSIS
WHO TO SCREEN! Patients with type 1 DM annually from 5 years after diagnosis Patients with type 2 DM annually from time of diagnosis

DIAGNOSIS
ABNORMAL TESTS Exclude recent(24hrs) vigorous exercise,fever,heart failure,urine infection,prostatitis & menstruation. Confirm observation twice within 3-6 months Look for BP above target levels.

Screening for Diabetic Nephropathy


Test
Blood Pressure1

When
Each office visit

Normal Range
<130/80 mm/Hg

Urinary Albumin1

Type 2: Annually beginning at diagnosis Type 1: Annually, 5-years post-diagnosis

<30 mg/day <20 g/min <30 g/mgcreatinine

1American

Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004

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

Treatment of Diabetic Nephropathy (cont.)


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 End-Stage Renal Disease (ESRD)


There are three primary treatment options for individuals who experience ESRD:
1. Hemodialysis 2. Peritoneal Dialysis 3. Kidney Transplantation

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

Hemodialysis (cont.)
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

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

Peritoneal Dialysis (cont.)


Peritoneal Dialysis Diet
Limit salt and fluid intake Consume more protein Some potassium restrictions Reduce caloric intake

Complications
Peritonitis

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

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

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