Chronic Kidney Disease

(CKD) and Diabetes

June 20, 2007
Alfred K. Cheung, M.D.
University of Utah

Acknowledgement
National Kidney Foundation
K/DOQI

Current Terminology

Kidney, not Renal (or Reno)

CKD, not CRF
DKD (= diabetic nephropathy)
AKI, not ARF
Still ESRD (End Stage Renal Disease)
Still RRT (Renal Replacement Therapy)

ESRD Incidence Counts and Rates

by Primary Diagnosis (USRDS, 2006)

Better CKD
Management?

Glomerulus = filtering unit

Importance of Diabetic Kidney Disease

Kidney disease as diabetic complication:
30% of Type 1 Diabetes
40% of Type 2 Diabetes

CKD amplifies CVD risk of diabetes

Diabetic Kidney Disease Screening

WHEN
Type 1: after 5 years, then annually
Type 2: at diagnosis, then annually

HOW
Albumin-to-Creatinine ratio in random urine
Microalbuminuria = 30-300 mg/g
Macroproteinuria

Estimate GFR (eGFR) from serum creatinine

using formulas
Retinopathy: useful clue

Stages of CKD
Stage

ICD-9

GFR
(mL/min/1.73M2)

585.1

> 91 + damage

585.2

60-89 + damage

585.3

30-59

585.4

15-29

585.5

< 15

585.6

ESRD on RRT

Action Plan in the Clinic

Determine AKI vs. CKD?

Estimate GFR and rate of decline
Identify kidney disease requiring specific Rx
Slow progression of CKD
Review medications
Identify + treat systemic complications
Prepare for replacement therapy
Depending on CKD Stage

Formulas for Estimating GFR

Cockcroft-Gault
MDRD (Modification of Diet in Renal Disease Study)
GFR calculator (www.kidney.org)

GFR depends on:

Serum creatinine
Age
Gender
Race

Interventions to Slow CKD Progression

Strong evidence
Blood pressure control
ACEI / ARB
Glucose control in DM

Weaker evidence
Protein restriction
Lowering LDL cholesterol

Management of Albuminuria
in Normotensive Diabetic
Normotensive DM patients with
macroalbuminuria should be treated with
ACEI / ARB
Treatment with an ACE inhibitor or an ARB
should be considered in normotensive
persons with diabetes and
microalbuminuria

AKI Superimposed on CKD

Dehydration
BP too low
Obstruction
Contract dye
Drugs
Nephrotoxic or allergic or hemodynamic
NSAID (including Cox-2 inhibitors)
ACEI / ARB

Systemic Complications of CKD

Hypertension
Cardiovascular disease
Anemia
Calcium-phosphorus-parathyroid

American Heart Association

Patients with CKD
Should be considered as highest-risk group
for CVD
Should be treated as such

Sarnak, Circ, 2004

Left Ventricular Hypertrophy in CKD

Risk factors: HTN and Anemia

Levin, AJKD. 1999; Foley, KI, 1995

Erythropoietin Stimulating Agent in CKD

Administration (SQ q 1-4 wk)
Epoietin- (start 75-150 units/kg)
Darbepoetin (start 0.45 g/kg)

Target Hgb (11-12 g/dL)

Adverse effects
Iron deficiency (may need IV iron)
Hypertension

What is Renal Diet?

Low sodium
Low potassium
What about DASH?

Low phosphorus
Adding glucose and fat targets?

Should be individualized

Symptoms of Uremia

None or subtle
Fatigue, lack of energy
Anorexia (nausea/vomiting)
Sleep disturbance
Impaired cognitive function
Impotence

When to Start Replacement Therapy

Phophorus higher than hct

Pale and sallow
Needs a razor blade to scratch the itch
Vomiting day & night
Legs twitching
Hands flapping
Uremic smell you cannot stand

Too late!!
Should start no later than mildly symptomatic
Usually GFR 7-8 mL/min

Preparation for RRT

GFR 20 mL/min (depends on rate of decline)
Early CKD education (including diet)
Early nephrology referral for co-management
(delineate responsibilities)
Arm vein preservation