Diabetes and Kidney Disease

1
Diabetes and Kidney Disease
Presentation DCPNS Complications Round Table,
June 25, 2003

• by
• Steven Soroka MD
• Division of Nephrology, Department of Medicine
  Dalhousie University

2
Prevalent ESRD patients by modality, Canada,
1981-1999
12,000
10,000
8,000
6,000
Number
4,000
2,000
0
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Haemodialysis
Peritoneal Dialysis
Funct Tx
3
End-stage Renal Disease Patients with Diabetes by
Province, Canada, 1990 and 1999 ( of new cases)
40
35
30
25
20
15
10
5
0
BC
AB
SK
MB
ON
QC
Atlantic
Diabetic 1990
Diabetic 1999
Source CORR/CIHI 2001
4
Incidence of end-stage renal disease by age
group, Canada, 1990-1999
50.4
Source CORR/CIHI 2001
5
Primary Renal Disease of New Patients, Canada,
1999
Unknown
13
Other
11
Polycystic
Kidney
4
Pyelonephritis
5
Other Renal
Glomer.
Hypertension
Vascular
15
13
8
Source CORR/CIHI 2001
6
Cause of Death of all Registered Patients,
Canada, 1999
Cardiac Disease
Uncertain
30
18
Other
19
Social
15
Infection
10
Social includes patient refused further
treatment, suicide, and therapy discontinued for
any other reason. Source CORR/CIHI 2001
7
Cardiovascular Mortality
Foley,et al. General Population (NCHS) vs ESRD
(USRDS)
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General Recommendations

• Risk Factor Assessment and Documentation
• - Initial Visit
• - Follow up Visit
• Achieve Established Treatment Targets
• - Patient Education
• - Collaborative Care with Primary Care Physician
• - Referral for Subspecialty Care

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Risk Factors for Diabetic Nephropathy

• Family History of Hypertension or Kidney Disease
• Smoking
• Hypertension
• Dyslipidemia
• Decreased Kidney Function
• A1C gt 8.5
• Duration of Diabetes
• - Type 1 gt 10 years
• - Type 2 gt 5 years

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Specific Recommendations

• Blood Pressure Measurement
• Measuring Kidney Function
• Cockcroft-Gault Formula
• (140 age) X wt / Creatinine
• Multiply by 1.2 if male

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Kidney Disease Screening

• Couchoud, et al Kidney International, 1999

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Stages of Chronic Kidney Disease
KDOQI, Am J Kid Dis, 2002
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Diabetic Nephropathy Screening in Type 2
Diabetesa practical approach for Nova Scotia

• Routine urinalysis at diagnosis then annually
• If Positive then quantitative test
• If Negative
• Treat if Hypertension or other CVD Risk Factors
• Test for MicroAlbuminuria
• If no Hypertension and no other risk factors
• Alb/Cr on Spot urine

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Test and Document Proteinuria

• Urine Albumin/Creatinine Ratio
•  
• Dipstick Albumin/Creatinine
• (mg/mmol)
• NORMAL Negative lt 2.0 men
• lt 2.8 women
• MAU Negative 2.0 20 men
• 2.8 28 women
• Diabetic Nephropathy Positive gt 20 men
• gt 28 women

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Treat Blood Pressure To Target

• Target 130/80 or 125/75
• Na Restrict 2 g Na (100 mM)
• ACEi or ARB
• Need 3 4 medications
• Refer to local Internist for patients not
  controlled by 3 agents

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Prevalence of Hypertension in Type 2 Diabetes
Normoalbuminuria (UAE ? 30 mg/day) Microalbuminuri
a (UAE 30-300 mg/day)
Macroalbuminuria (UAE ? 300 mg/day) All patients
100
93
90
80
71
Prevalence of hypertension ()
50
0
n323
n151
n75
n549
Hypertension defined as ³140/90 mm Hg. UAE
urinary albumin excretion
Tarnow L et al. Diabetes Care 1994171247-1251.
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Number of Antihypertensives Neededto Achieve
Target Blood Pressure
AASK (lt 92 mm MAP)
HOT (lt 80 mm DBP)
MDRD (lt 92 mm MAP)
ABCD (lt 75 mm DBP)
UKPDS (lt 85 mm DBP)
0
1
2
3
4
Bakris et al. AJKD 2000
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Intensive Blood Pressure Control
IBP -1,959/QALY
JAMA, 2002 CMAJ 1992146473
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Refer To Nephrology

• CrCl lt 30 ml /min measured on at least 2
  occasions.
• Atypical features hematuria, systemic disease,
  rapidly rising Cr, or increased.
• ? Cr gt 30 after ACEi or ARB.
• Nephrotic syndrome gt 3.5 g/day proteinuria with
  or without low albumin, increased cholesterol,
  edema, or hypertension.

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Education

• Patient Education
• - Lifestyle modification
• - Na restriction
• - Smoking cessation
• - Weight loss
• Health Care Professional Education
• Community Based Approach