Diabetic Nephropathy

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Diabetic Nephropathy
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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

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Five Stages of Kidney Disease
Stage 1 Hyperfiltration, or an increase in
glomerular filtration rate (GFR) occurs. Kidneys
increase in size. Stage 2 Glomeruli begin to
show damage and microalbuminurea occurs. Stage
3 Albumin excretion rate (AER) exceeds 200
micrograms/minute, and blood levels of creatinine
and urea-nitrogen rise. Blood pressure may rise
during this stage.
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Five Stages of Kidney Disease (cont.)
Stage 4 GFR decreases to less than 75 ml/min,
large amounts of protein pass into the urine, and
high blood pressure almost always occurs. Levels
of creatinine and urea-nitrogen in the blood rise
further. Stage 5 Kidney failure, or end stage
renal disease (ESRD). GFR is less than 10 ml/min.
The average length of time to progress from Stage
1 to Stage 4 kidney disease is 17 years for a
person with type 1 diabetes. The average length
of time to progress to Stage 5, kidney failure,
is 23 years.
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Screening for Diabetic Nephropathy
1American Diabetes Association Nephropathy in
Diabetes (Position Statement). Diabetes Care 27
(Suppl.1) S79-S83, 2004
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Treatment of Diabetic Nephropathy

• Hypertension Control - Goal lower blood pressure
  to lt130/80 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

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Treatment of Diabetic Nephropathy (cont.)

• Glycemic Control
• Preprandial plasma glucose 90-130 mg/dl
• A1C lt7.0
• Peak postprandial plasma glucose lt180 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

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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

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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

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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

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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

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Peritoneal Dialysis (cont.)

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

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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

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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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How Can You Prevent Diabetic Kidney Disease?

• Maintain blood pressure lt130/80 mm/Hg
• Maintain preprandial plasma glucose 90-130 mg/dl
• Maintain postprandial plasma glucose lt180 mg/dl
• Maintain A1C lt7.0

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References

• American Diabetes Association Nephropathy in
  Diabetes (Position
• Statement). Diabetes Care 27 (Suppl.1) S79-S83,
  2004
• National Kidney and Urologic Diseases Information
  Clearinghouse.
• Kidney Disease of Diabetes. Bethesda, MD
  National Institute of
• Diabetes and Digestive and Kidney Diseases,
  National Institutes of
• Health (NIH), DHHS 2003.
• United States Renal Data System. USRDS 2003
  Annual Data
• Report. Bethesda, MD National Institute of
  Diabetes and Digestive
• and Kidney Diseases, National Institutes of
  Health (NIH), DHHS
• 2003.
• DeFronzo RA Diabetic nephropathy etiologic and
  therapeutic
• considerations. Diabetes Reviews 3510-547, 1995
• National Kidney and Urologic Diseases Information
  Clearinghouse.
• Kidney Failure Choosing a Treatment Thats Right
  For You.
• Bethesda, MD National Institute of Diabetes and
  Digestive and