Case Study

Dr. Santi Syafril, SpPD-KEMD

 Patient profile
• Mr. C, 51 years old, retired. He complained of
foaming urine since 2 months and both of his feet
become swollen after sitting or standing for long
time.
• He had DM since 2 years, and consumed metformin
500 mg tid and pioglitazone 30 mg once daily. He
had history of hypertension and treated with
amlodipine 5 mg/day.
• Currently, he felt scared because many friends are
undergoing hemodialysis and having heart attack
due to Diabetes Mellitus. He do exercise regularly,
walking everyday for 30 minutes until 1 hour,
sometimes swimming and cycling.
 Physical Examination

• Height 162 cm, Weight 66 kgs, BMI 25,1 kg/m2

Waist circumference 98 cm.
• BP 130/90 mmHg, pulse 72 x/m
• Heart/Lung normal
• Extremity normal
 Laboratory

• FBG 184 mg/dL PPBG 318 mg/dL HbA1c 8.6 %

• Cholesterol total 205 mg/dL
• LDL cholesterol 120 mg/dL
• HDL cholesterol 42 mg/dL
• Triglyceride 148 mg/dL
• Ureum 36 mg/dL Creatinin 1.4 mg/dL eGFR 57
ml/min/1.73 m2
• ACR 280 mg/gram
• ECG: sinus rythme, 76 x/minutes, no T inversion, no
ST elevation or ST depression
• Chest X-ray: no cardiomegaly
 Discussion case

1. What is the problem with this patient?

2. What are we going to do with the patient?
3. How is the glycemic goal for this patient?
4. What treatment is appropriate for the patient?
 1. What is the problem with this patient?

• Uncontrolled type 2 DM
• Hypertension
• Obesity
• Dyslipidemia
• Diabetic nephropathy
• CKD ?
• Swollen of his feet after sitting or standing
for long time.
2. What are we going to do with the patient ?

• Screening for microangiopathy

- neuropathy : monofilamen, tuning fork, etc
- retinopathy : funduscopy
- nephropathy : urine albumin, creatinin
serum, albumin to creatinin ratio (ACR)

• Screening for macroangipathy

- CAD : chest X Ray, ECG, etc
- PAD : dorsalis pedis and tibialis posterior
artery pulsation, ABI, etc
 Recommendations for nephropathy screening
in diabetes

American Diabetes Association recommendations 2017

Level of evidence B:

At least once a year, assess urinary albumin (e.g., spot

urinary albumin–to–creatinine ratio) and estimated
glomerular filtration rate (eGFR) :
- in patients with type 1 diabetes with duration of
5 years
- in all patients with type 2 diabetes
- in all patients with comorbid hypertension.
• The urine albumin to creatinine ratio can be measured on a spot
or timed urine collection such as 4 or 24 h.
- Microalbuminuria is defined as >30 mg/g creatinine or
30 mg per 24 h.
- Clinical or macroalbuminuria is defined as >300 mg/g
creatinine or 300 mg per 24 h.

• An abnormal value should be confirmed on at least one additional

urine specimen over a 6 month period.

• Two of three specimens of UACR collected within a 3- to 6-

month period should be abnormal before considering a patient to
have albuminuria (ADA 2018).

• Recently, the terms “moderately increased” and “severely

increased” albuminuria have been introduced to replace the
terms “microalbuminuria” and “macroalbuminuria”.
3. How is the glycemic goal for this patient?
 Glycemic goal in CKD

• Glycemic control is essential to delay or possibly

prevent nephropathy :
- ADA : target A1c ≤7 %, higher (<8 %) or stricter
(< 6.5 %) for certain populations.

- AACE : target A1c ≤6.5 % in healthy patients who

are at low risk for hypoglycemia but the goals
need to be individualized.

- KDOQI 2007 : target A1c of <7.0 %

- KDOQI 2012 : target A1c of ~7.0 %.
 Accuracy of A1c in CKD

Falsely elevated HbA1c Falsely decreased HbA1c

Uremic toxins Decreased ½ life RBCs

Metabolic acidosis Blood transfusion
EPO treatment
Iron deficiency

May need to change to glycated fructosamine, glycated

albumin (an estimate of control over the past 2 weeks)
and 1,5- anhydroglucitol .

Kovesdy CP et al, AJKD 2008, 52: 766

Cohen RM et al, Diabetes Care. 2003 Jan;26(1):163-7 McCarter RJ et al,
Diabetes Care. 2004 Jun;27(6):1259-64
4. What treatment is appropriate for the
patient?
 Blood Glucose Control
Potential limitations of glucose-lowering agents in patients with
diabetic kidney diseases
Dose adjustment for insulin compounds and
medications for diabetes in CKD
Dose adjustment for insulin compounds and
medications for diabetes in CKD
Dose adjustment for insulin compounds and
medications for diabetes in CKD
Dose Adjustment for Insulin Compounds and Oral Medicines for
Diabetes in CKD (NKF KDOQI, 2012 )
Recommended dose adjustments for noninsulin antihyperglycemic
agents in DKD (ADA Consensus Conference, 2014 )
 Blood Pressure and Lipid Control

• KDIGO 2012 guidelines on BP and lipid management

have recommended in DKD :
- single-agent RAS blockade and BP targets below
130/80 mm Hg in patients with diabetes and
albuminuria (urinary ACR >3 mg/mmol or >30 mg/g)
- along with routine treatment with fixed-dose,
moderate-intensity statin with or without
ezetimibe
- No recommendation for initiating statin therapy in
patients with diabetes who are treated by dialysis.
(1B)
American Diabetes Association recommendations
2017

• Level of evidence A:
control BP (goal <140/90mmHg, <130/80 only for
younger patients)
control glycemia (A1C about 7%, personalized)
control dyslipidemia (LDL goal <70-100 mg/dl)
counsel about smoking cessation
education

• Level of evidence B:
protein intake to 0.8 mg/kg/day (more if
dialysis)
ADA recommendations, Diabetes Care, January 2017
 ACEi or ARB?

ADA 2018 :
• ACE i or ARBs is recommended for those with modestly
elevated urinary ACR(30–299 mg/g creatinine) ( Level B )
• ACE i or ARBs is strongly recommended for those with urinary
ACR ≥300 mg/g creatinine and/or estimated GFR <60
mL/min/1.73 m2 ( Level A ).

ADA 2017 :
• Type 1 DM with HTN and albuminuria: ACEi
• Type 2 DM with HTN and microalbuminuria: either ACEi or ARBs
• Type 2 DM with HTN and overt nephropathy: ARBs
• When not tolerated, substitute one for the other

Combination not supported

 Albuminuria Control

• In general, ACEi and ARBs are considered to have similar

benefits and risks.

• In the setting of lower levels of albuminuria (30–299 mg/g

Cr), ACEi or ARB therapy has been demonstrated to
reduce progression to more advanced albuminuria (>300
mg/g Cr) and cardiovascular events but not progression to
ESRD.
•
• While ACEi or ARBs are often prescribed for albuminuria
without hypertension, clinical trials have not been
performed in this setting to determine whether this im-
proves renal outcomes.

ADA, 2018
Thank You