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Transcript of 092210.fbrosius.diabeticnephropathy
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Author(s): Frank Brosius, M.D, 2011
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Kidney Systemic Disease Diabetes
Frank Brosius, M.D.
Fall 2010
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Diabetic Nephropathy--Objectives
• Understand pathology and pathogenesis
• Identify early clinical predictors or indicators
• Describe most important therapeutic interventions to prevent progression
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Diabetic Nephropathy:“You can't cure it so you have to endure it”
King, et al. Qual Health Res. 2002;12:329-46
American Diabetes Association
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Diabetes is the dominant cause of ESRD in USA
Incident ESRD patients; Medical Evidence form data; rates adjusted for age, gender, & race.
USRDS 2009U.S. Renal Data System, 2009
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Incidence rates of ESRD (per million population): 1997
USRDS 2009
Incident ESRD patients, by HSA; rates adjusted for age, gender, & race. Excludes patients residing in Puerto Rico & the Territories.
U.S. Renal Data System, 2009
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Incidence rates of ESRD (per million population): 2007
USRDS 2009
Incident ESRD patients, by HSA; rates adjusted for age, gender, & race. Excludes patients residing in Puerto Rico & the Territories.
U.S. Renal Data System, 2009
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Obesity, metabolic syndrome and type 2 diabetes mellitus
CalorieLab® based on the Behavioral Risk Factor Surveillance System database maintained by the CDC. Rankings use a three-year average for smoothing.
CalorieLab
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Adjusted five-year survival, by modality & primary diagnosis: 1993-2002: still lousy
USRDS 2009
Incident dialysis patients & patients receiving a first transplant in the calendar year. All probabilities are adjusted for age, gender, & race; overall probabilities are also adjusted for primary diagnosis. All ESRD patients, 1996, used as reference cohort. Modality determined on first ESRD service date; excludes patients transplanted or dying during the first 90 days (five-year survival probabilities noted in parentheses). U.S. Renal Data System, 2009
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Int J Radiat Oncol Biol Phys. 2005 Jul 15USRDS 2009
Diabetic nephropathy = Cancer
Adjusted five-year survival, by modality & primary diagnosis: 1998-2002: still lousy
ESRDNon–small-cell lung cancer
AJCC stage: IIIA or IIIB
U.S. Renal Data System, 2009
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15-20%
American Diabetes Association
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• Genetic factors (familial clustering)• Hyperglycemia• Hypertension• Glomerular hyperfiltration/hypertension• Smoking• Male gender• Advanced age• Race
Risk factors for renal disease in Type II DM
UpToDate, 2010
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ELMO1, NOS3, etc
Family Investigation of Nephropathy of
Diabetes (FIND) Consortium
Genetic factors
American Diabetes Association
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Hyper-glycemia
American Diabetes Association
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December 31 point prevalent ESRD patients; rates adjusted for age & gender. USRDS 2009
Race: Diabetes is the
dominant cause of ESRD in USA
…more so in AAs
U.S. Renal Data System, 2009
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Screening
American Diabetes Association
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Screening for diabetic nephropathy:1) Microalbuminuria
from Standards of Medical Care in Diabetes—2010DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
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Evaluation of microalbuminuria
• Test type 1 patients after 5 years and every year thereafter
• Test type 2 patients every year• If positive, rule out transient causes of
microalbuminuria (e.g., CHF, exercise (within 24 hr), infection, fever, severe HTN)
• Repeat 2 times in 3-6 months
– Microalbuminuria = 2/3 tests positive.
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Screening for diabetic nephropathy:2) Estimate GFR
“Measure serum creatinine at least annuallyin all adults with diabetes regardlessof the degree of urine albuminexcretion. The serum creatinine shouldbe used to estimate GFR and stage thelevel of chronic kidney disease (CKD),if present.”
from Standards of Medical Care in Diabetes-2010DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2010
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Pathology
American Diabetes Association
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Source Undetermined
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Pathology of DM nephropathy
Normal Glomerulus Early Diabetic Glomerulus
Capillary lumen
Mesangial cell
Thickened BM
Expanded mesangium
Mesangium
Podocyte damage & loss
Basement membrane
– Afferent and efferent hyaline arteriolosclerosis– Interstitial fibrosis and tubular atrophySource Undetermined
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Normal glomerulus Diffuse mesangial sclerosis Nodular mesangial sclerosis
Pathology of DM nephropathy
Source Undetermined
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Pathology of DM nephropathy
Normal Glomerulus Early Diabetic Glomerulus
Capillary lumen
Mesangial cell
Thickened BM
Expanded mesangium
Mesangium
Podocyte damage & loss
Basement membrane
– Afferent and efferent hyaline arteriolosclerosis– Interstitial fibrosis and tubular atrophySource Undetermined
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Podocyte loss predicts
progression of nephropathy
Podocyte number
Podocyte number
Alb
umin
uria
4 y
rs la
ter
Incr
. in
albu
min
uria
in 4
yrs
Meyer, et al. Diabetologia. 1999;42:1341
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Pathogenesis
American Diabetes Association
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?
Source Undetermined
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Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaGenetic factors metabolism of glom. cells
Simpleminded model of pathogenesis of DM nephropathy
from T. Hostetter
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Source Undetermined
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Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaGenetic factors metabolism of glom. cells
Simpleminded model of pathogenesis of DM nephropathy
from T. Hostetter
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TGF-AII
stretch
NADH/NAD
PKC
TGF-
fibronectincollagen IV
GLUT1
ERKs
AGEsROS
glucose sorbitol fructose
DAG
glucose
Potential mechanisms for increased matrix production in hyperglycemia
Mesangial cell
Source Undetermined
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Unified field theorem for diabetic complications: oxidative stress rules
Brownlee, Nature, 414:813, 2001 Brownlee, Nature, 414:813, 2001
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…or maybe it’s all inflammation?
Scmid et al., Modular activation of nuclear factor-kappaB transcriptional programs in human diabetic nephropathy. Diabetes, 2006; 200;55:2993
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Treatment
American Diabetes Association
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Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaGenetic factors metabolism of glom. cells
TreatmentTreatment of DM nephropathy:Glucose control
from T. Hostetter
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The Diabetes Control And Complications Trial (DCCT) 1993
1400 INDIVIDUALS WITH IDDM
CONVENTIONAL INSULIN THERAPY
INTENSIVE INSULIN THERAPY
CONTROL OF Sx’s. NORMALIZE BLOOD SUGAR
Does long-term normalization of blood glucose levels in type 1 diabetes reduce the risk of development or progression of microvascular complications?
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The Benefits of “Tight Control”: The DCCT
Rate/100 pt-yrs. Rate/100 pt-yrs.
Intensive metabolic control dramatically reduced the risk of developing or worsening microvascular complications in type 1 diabetes.
The United Kingdom Prospective Diabetes Study (UKPDS), demonstrated very similar results in individuals with type 2 diabetes.
INTENSIVE
CONVENTIONAL
30405060708090100
RETINOPATHY
NEPHROPATHY
NEUROPATHY
30405060708090
100
DCCT RESULTS: The Good News
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Intensive insulin Rx prevents diabetic nephropathy for years after (EDIC)
HbA1c levels after end of DCCT Cumulative incidence of nephropathy
Arch Int Med; 2009;169(14):1307 Arch Int Med; 2009;169(14):1307
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American Diabetes Association
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Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaGenetic factors metabolism of glom. cells
TreatmentTreatment of DM nephropathy:Hypertension control
from T. Hostetter
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Effect of antihypertensives on progression of DM nephropathy
Rate of declineIn GFR (ml/min/mo.)
MAP post Rx(mmHg)
111 99 114Source Undetermined
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Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaGenetic factors metabolism of glom. cells
TreatmentTreatment of DM nephropathy:Effect of ACEIs and ARBs
from T. Hostetter
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DMACEI or ARBSource Undetermined
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Delaying nephropathy with ACE inhibitors
Lewis et al., NEJM 329:1456, 1993 Lewis et al., NEJM 329:1456, 1993
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Delay of diabetic nephropathy in type 2 patients with ARBs
RENAAL Reduction of endpoints in non-insulin-dependent diabetes mellitus with the angiotensin II receptor antagonist losartan
IDNT Irbesartan diabetic nephropathy trial
IRMA-II irbesartan in patients with type II diabetes and microalbuminuria
NEJM, 2001ARB = angiotensin receptor blocker
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Delay of diabetic nephropathy in type 2 patients with ARBs
RENAAL and IDNT-- •pts with established overt nephropathy•Age = 60 (IDNT)•virtually all pts hypertensive; groups had similar BPs•endpoints = 2x serum creatinine, ESRD, death•20-33% reduction in endpoints in ARB treated pts vs control or amlodipine-treated pts
IRMA-II • reduction in proteinuria and rate of progression to overt nephropathy in type 2 pts with microalbuminuria
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Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaGenetic factors metabolism of glom. cells
TreatmentTreatment of DM nephropathy:Effect of dietary protein restriction
from T. Hostetter
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Effect of dietary protein restriction on progression of DM nephropathy
GFR(ml/min)
Source Undetermined
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TreatmentTreatment of DM nephropathy:Effect of statins
from T. Hostetter
Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaROSGenetic factors metabolism of glom. cells
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Effects of lipid lowering on progression of diabetic nephropathy
Fried, et al., Kidney Int, 2001; 59:260 Fried, et al., Kidney Int, 2001; 59:260
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Renal preglomerular vasodilation
Systemic hypertension
Glomerular hypertension
Glomerular sclerosis
HyperglycemiaROSGenetic factors metabolism of glom. cells
from T. Hostetter
TreatmentTreatment of DM nephropathy:All together!
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Likelihood of regression
Remission of microalbuminuria
NEJM 348: 2265, 2003 NEJM 348: 2265, 2003
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?
American Diabetes Association
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0 yr 5 yr 10 yrtime after Tx
Remittive effect of pancreas Tx on DM
nephropathy
GBM TBM
Mesangial fx. vol Matrix fx. vol
Fioretto, et al. N Engl J Med. 1998, 339:69
Fioretto, et al. N Engl J Med. 1998, 339:69
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Remittive effect of long term ACEI on chronic nephropathies
Ruggenenti, JASN10:997, 99
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Remission of microalbuminuria results in fewer cardiovascular
and kidney events
N=123
N=93
Araki, et al., Diabetes. 2007 Jun;56:1727
Araki, et al., Diabetes. 2007 Jun;56:1727
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Clinical course — M.W. (34 yo female with type 1 DM for 33.5 yrs)
020406080
100120140
0
0.5
1
1.5
2
2.5
3
97 98 99 00 01 02 03 04 05
Estim
ated
GFR
(ml/m
in)
U P
ro/c
reat
BP = 133/83
BP = 100/70
0
0.5
1
1.5
2
2.5
3
3.5
4
07 08 09
Pregnancy
Last eGFR = 47 ml/min
Stopped ACEI
Source Undetermined
Source Undetermined
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Diabetic Nephropathy:“You can't cure it so you have to endure it”
020406080
100120140
0
0.51
1.5
22.5
3
97 98 99 00 01 02 03 04 05
Estim
ated
GFR
(ml/m
in)
U P
ro/c
reatWith current treatment,
we can keep patients stable or in remission for years…..
But can we do better?
American Diabetes Association
Source Undetermined
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Management of Diabetic Nephropathy-Dx
• Screen for microalbuminuria and eGFR (1x/yr).
• Identify high risk patients.
• Monitor BP, blood glucose closely at home.
• Monitor for macrovascular disease.
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• Normalize BP. Target <130/80.
• Treat with ACE inhibitors or ARBs.
• Treat hyperlipidemia and hyperglycemia aggressively.
• Moderate protein restriction (0.8- 1.0 gm/kg/day).
• Treat cardiovascular disease aggressively.
• Refer to nephrologist early in course of azotemia.
Management of Diabetic Nephropathy-Rx
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Slide 5: American Diabetes AssociationSlide 6: U.S. Renal Data System, 2009, http://www.usrds.org/Slide 7: U.S. Renal Data System, 2009, http://www.usrds.org/Slide 8: U.S. Renal Data System, 2009, http://www.usrds.org/Slide 9: CalorieLab, http://calorielab.com/index.html Slide 10: U.S. Renal Data System, 2009, http://www.usrds.org/Slide 11: U.S. Renal Data System, 2009, http://www.usrds.org/Slide 12: American Diabetes AssociationSlide 14: American Diabetes AssociationSlide 15: American Diabetes AssociationSlide 16: U.S. Renal Data System, 2009, http://www.usrds.org/Slide 17: American Diabetes AssociationSlide 18: Standards of Medical Care in Diabetes—2010 DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010Slide 20: Diabetes Care, 23:S69, 2000Slide 21: American Diabetes AssociationSlide 22: Source UndeterminedSlide 23: Source UndeterminedSlide 24: Source UndeterminedSlide 25: Source UndeterminedSlide 26: Meyer, et al. Diabetologia. 1999;42:1341 Slide 27: American Diabetes AssociationSlide 28: Source UndeterminedSlide 30: Source UndeterminedSlide 32: Source UndeterminedSlide 33: Brownlee, Nature, 414:813, 2001Slide 34: Scmid et al., Modular activation of nuclear factor-kappaB transcriptional programs in human diabetic nephropathy. Diabetes, 2006; 200;55:2993Slide 35: American Diabetes AssociationSlide 39: Arch Int Med; 2009;169(14):1307Slide 40: American Diabetes AssociationSlide 42: Source UndeterminedSlide 44: Source UndeterminedSlide 45: Lewis et al., NEJM 329:1456, 1993Slide 49: Source UndeterminedSlide 51: Fried, et al., Kidney Int, 2001; 59:260Slide 53: NEJM 348: 2265, 2003Slide 54: American Diabetes AssociationSlide 55: Fioretto, et al. N Engl J Med. 1998, 339:69Slide 56: Ruggenenti, JASN10:997, 99Slide 57: Araki, et al., Diabetes. 2007 Jun;56:1727Slide 58: Source UndeterminedSlide 59: American Diabetes Association; Source Undetermined
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