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Diabetic Nephropathy

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Sue Saunders

on 2 April 2013

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Transcript of Diabetic Nephropathy

Questions Kidney Foundation of Canada (2006). Living with Kidney Disease Manual, 4th edition

Public Health Agency of Canada. Diabetes in Canada: Facts and Figures from a Public Health Perspective, Ottawa, 2011. Retrieved on March 26, 2013 from: http://www.phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffres-eng.pdf

Sego, S. Pathophysiology of Diabetic Nephropathy, Journal of Nephrology Nursing, 2007. 34(6): 631-3.

Stigant C, Stevens L, Levin A. Nephrology: 4. Strategies for the care of adults with chronic kidney disease. CMAJ 2003;168:1553-60.

Weir, M., Renal effects of non selective NSAIDS and coxibs. Cleveland Clinic Journal of Medicine, 2002; 68, suppl 1: S153-58.

World Health Organization Diabetes Fact Sheet, March 2013. Retrieved March 26, 2013 from: http://who.int/mediacentre/factsheets/fs312/en/index.html References Individualized based on patient lab work and type of dialysis treatment
Changes to the diabetic diet may include:
Low potassium-orange juice, tomatoes, potatoes
Low phosphorus- avoiding whole grain, multigrain, sardines, herring, chocolate, colas
Low fat
Low salt- avoiding processed food (also high in phosphorus), reduce salt to <1.5g/day Diabetic renal diet Considerations when caring for a diabetic patient with CKD Associated with increase prevalence of renal toxicity (Weir, 2002)
Can increase blood pressure with combined use with ACEi, ARB or diuretic
Avoid Ibuprofen, Advil, Aleve, Naproxen, Celebrex Avoid Non steroidal anti-inflammatory medication Early treatment can prevent or delay the onset of ESRD
(Canadian Society of Nephrology, 2008) Slowing the progression of CKD in the diabetic patient Presence of protein in the urine
Microalbuminuria- 30-300 mg albumin/24hr
Macroalbuminuria- >300mg albumin/24hr
Albumin to Creatinine ratio >60 mg/mmol
GFR <60 ml/min/1.73m²
Renal biopsy for definitive diagnosis
Renal ultrasound
Canadian Society of Nephrology Clinical Practice Guidelines, 2008 Diagnosis of diabetic nephropathy Definition: Chronic Kidney Disease caused by diabetes
34% of all newly diagnosed CKD patients have diabetes (Public Health Agency of Canada, 2011)
Most prevalent cause of CKD (Canadian Society of Nephrology, 2008; CIHI 2011)

A decrease in oxygenated blood flow in the small blood vessels in the glomerular capsule
Irreversible damage to the nephrons (functional unit of the kidneys) and the glomeruli (filters)(Sego, 2007) Diabetic Nephropathy Hyperglycemia damages blood vessels in the body leading to macrovascular (CAD, PVD, CVA) and microvascular (diabetic nephropathy, retinopathy and neuropathy) complications (Fowler, 2008) Inadequate response by the pancreatic Beta cells to high blood sugars (Type 2)
Inadequate production of insulin by the pancreas (Type 2)
Inability of pancreas to produce insulin (Type 1)

Insulin allows the cells in the body to absorb sugar
from the bloodstream
(Canadian Diabetes Association, 2013) What is diabetes? Avoid meperidine- metabolite accumulation
Depending on medication and GFR, dosages need to be adjusted
Amoxicillin
Cephalexin
Ciprofloxacin
Trimethoprim/sulfamethoxazole
Digoxin
Gabapentin
Lithium
Metoclopramide
fenofibrate
Avoid radiocontrast dye Medications 1) Smoking cessation – reduce risk of progression of CKD and cardiovascular diseases
2) weight loss BMI <25 Lifestyle changes Treat dyslipidemia
Goal: TC/HDL <4.0 and LDL <2.0 mmol/L
First choice of medication: Statin
Aspirin 81 mg/day – prevention of heart attack or stroke Reducing cardiovascular risk Blood pressure control Glycemic control- HbA1C <7%

Glyburide- metabolized in liver but active metabolites removed by the kidney

Metformin- linked with lactic acidosis in CKD patients GFR <30ml/min

Insulin
40-50% is eliminated by the kidneys
Reduce dosages in CKD patients Glycemic control in the CKD patient Filtration of blood to remove wastes
Removes excess fluid from the body
Releases hormones
Erythropoietin-triggers the production of red blood cells
Renin-helps control blood pressure
Calcitriol (active form of vitamin D) affects bone and mineral metabolism
Contributes to acid-base balance in the body
Removes excess salt, potassium and other electrolytes What are the functions of a healthy kidney? Obesity- abdominal fat releasing cytokinines contributing to insulin resistance (Freemantle et. al., 2008)
Uncontrolled blood sugars
Hypertension
Dyslipidemia
Ethnicity- First Nations, South Asian, African, Caribbean, Hispanic
Sedentary lifestyle
Smoking Risk Factors for Diabetic Nephropathy Not curable, but if caught in early stages, progression can be slowed or halted (BCPRA, 2011)

Death from cardiovascular events is eight times higher in the CKD population, higher than death from cancer Chronic kidney disease Stages of Chronic Kidney Disease Impaired fasting glucose and impaired 2 hr plasma glucose tolerance test
Polyuria
Polydipsia
Unexplained weight loss

Prediabetes - fasting blood sugar greater than 7.0 mmol/L but not high enough for a diagnosis
(Canadian Diabetes Association, 2008 Clinical Practice Guidelines) Diagnosis 347 million adults worldwide have diabetes
Estimates 552 million by 2030 (WHO, 2013; IDF, 2011)
>2.4 million Canadians are living with diabetes
Approximately
10% have Type 1 diabetes
90% have Type 2 diabetes
2-4% have gestational diabetes
(Public Health Agency of Canada, 2011) Diabetes Diabetes
Diabetic Nephropathy; Chronic kidney disease
Symptoms of CKD
Treatment for CKD
Slowing the progression of diabetic nephropathy
How is the treatment for diabetes different from the treatment for diabetic nephropathy?
Conclusion
Questions/comments Overview Presented by: Sue Saunders, RN, MScN, CNeph(C) Caring for the diabetic patient with kidney disease Diabetic Nephropathy GFR is an estimate of the excretory function of the kidney
Variability in e-GFR
Trending of e-GFR values Glomerular filtration rate Prevention

Peritoneal Dialysis

Hemodialysis

Transplantation

Conservative How to care for a renal patient? Cardiovascular events- Myocardial infarction, Stroke
Foaming urine
Fatigue
Anemia
Bone disease
Insomnia
Nausea
Leg cramps
Digestive problems
Edema What can happen at lower stages of CKD? Conclusion Diabetes is the primary cause for over 1/3 of chronic kidney disease in the world today
Diabetic nephropathy is a microvascular disease affecting the small blood vessels in the nephron and damaging glomeruli
Early intervention is the key to delay of End Stage Renal disease
Diabetic renal patients have unique challenges related to diet, medications and blood pressure control
BCMA Guidelines and Protocols, Chronic Kidney Disease- Identification, Evaluation and Management of Patients, September 15, 2008.

Canadian Institute for Health Information, Canadian Organ Replacement Register Annual Report: Treatment of End- Stage Organ Failure in Canada, 2000-2009 (Ottawa, Ont: CIHI, 2011).

Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification, American Journal of Kidney Diseases, 2002: 39(suppl 1)

Coresh et al., Prevalence of Renal Insufficiency in the U.S., AJKD, 2003, 41(1), 1-12

de Jong PE and Brenner BM. From secondary to primary prevention of progressive renal disease: the case for screening of albuminuria. Kidney Int 2004; 66: 2109-2118. Freemantle, N.,Holmes, J.,Hocky, A., 62(9): 1391-96.

Fowler, M. Microvascular and Macrovascular complications of diabetes. Clinical Diabetes, 2008; 26(2): 77-82

Go et al., Chronic Kidney disease and the risks of death, cardiovascular events, and hospitalizations. NEJM, 2004: 351(13).

Guidelines for the management of Chronic Kidney Disease (2008). Canadian society of Nephrology Clinical Practice Guidelines. http://csnscn.ca

International Diabetes Federation. IDF Diabetes Atlas, 5th edn. Brussels, Belgium: International Diabetes Federation, 2011. http://www.idf.org/diabetesatlas

Jardine, MJ., Prediction of kidney related outcomes in patients with Type 2 diabetes. American Journal of Kidney Diseases, 2012: 60(5): 770-78 Blood pressure control- 130/80 mmHg
ACEi or ARB- reduces urinary protein excretion while reducing BP
Diuretics, CCBlockers, Beta Blockers
Reducing salt in diet to < 1.5 g/day

(Canadian Society of Nephrology, 2008)
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