Chronic Kidney Disease (CKD) and Diabetes Treatment
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Chronic Kidney Disease Chronic Kidney Disease (CKD) and Diabetes(CKD) and Diabetes
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Medic Yatra Kidney FoundationMedic Yatra Kidney Foundation
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Current Terminology
• Kidney, not Renal (or Reno)
• CKD, not CRF
• DKD (= diabetic nephropathy)
• AKI, not ARF
• Still ESRD (End Stage Renal Disease)
• Still RRT (Renal Replacement Therapy)
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ESRD Incidence Counts and Ratesby Primary Diagnosis (USRDS, 2006)
Better CKD Management?
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Importance of Diabetic Kidney Disease
• Kidney disease as diabetic complication:– 30% of Type 1 Diabetes– 40% of Type 2 Diabetes
• CKD amplifies CVD risk of diabetes
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Diabetic Kidney Disease Screening• WHEN
– Type 1: after 5 years, then annually– Type 2: at diagnosis, then annually
• HOW– Albumin-to-Creatinine ratio in random urine
• Microalbuminuria = 30-300 mg/g• Macroproteinuria
– Estimate GFR (eGFR) from serum creatinine using formulas
– Retinopathy: useful clue
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Stages of CKDStage ICD-9 GFR
(mL/min/1.73M2)
1 585.1 > 91 + damage
2 585.2 60-89 + damage
3 585.3 30-59
4 585.4 15-29
5 585.5 < 15
6 585.6 ESRD on RRT
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Action Plan in the Clinic• Determine AKI vs. CKD?• Estimate GFR and rate of decline• Identify kidney disease requiring specific Rx• Slow progression of CKD• Review medications• Identify + treat systemic complications• Prepare for replacement therapy
Depending on CKD Stage
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Formulas for Estimating GFR• Cockcroft-Gault• MDRD (Modification of Diet in Renal Disease Study)
– GFR calculator (www.kidney.org)
• GFR depends on:– Serum creatinine– Age– Gender– Race
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Interventions to Slow CKD Progression
• Strong evidence– Blood pressure control– ACEI / ARB– Glucose control in DM
• Weaker evidence– Protein restriction– Lowering LDL cholesterol
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Management of Albuminuria in Normotensive Diabetic
• Normotensive DM patients with macroalbuminuria should be treated with ACEI / ARB
• Treatment with an ACE inhibitor or an ARB should be considered in normotensive persons with diabetes and microalbuminuria
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AKI Superimposed on CKD• Dehydration
• BP too low
• Obstruction
• Contract dye
• Drugs– Nephrotoxic or allergic or hemodynamic– NSAID (including Cox-2 inhibitors)– ACEI / ARB
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Systemic Complications of CKD
• Hypertension
• Cardiovascular disease
• Anemia
• Calcium-phosphorus-parathyroid
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American Heart Association
• Patients with CKD– Should be considered as highest-risk group
for CVD– Should be treated as such
Sarnak, Circ, 2004
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Left Ventricular Hypertrophy in CKD
Risk factors: HTN and AnemiaLevin, AJKD. 1999; Foley, KI, 1995
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Erythropoietin Stimulating Agent in CKD
• Administration (SQ q 1-4 wk)– Epoietin-α (start 75-150 units/kg)– Darbepoetin (start 0.45 μg/kg)
• Target Hgb (11-12 g/dL)
• Adverse effects– Iron deficiency (may need IV iron)– Hypertension
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What is Renal Diet?
• Low sodium
• Low potassium– What about DASH?
• Low phosphorus– Adding glucose and fat targets?
• Should be individualized
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Symptoms of Uremia
• None or subtle
• Fatigue, lack of energy
• Anorexia (nausea/vomiting)
• Sleep disturbance
• Impaired cognitive function
• Impotence
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When to Start Replacement Therapy• Phophorus higher than hct• Pale and sallow• Needs a razor blade to scratch the itch• Vomiting day & night• Legs twitching• Hands flapping• Uremic smell you cannot stand
• Too late!!• Should start no later than mildly symptomatic• Usually GFR 7-8 mL/min
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Preparation for RRT
• GFR 20 mL/min (depends on rate of decline)
• Early CKD education (including diet)
• Early nephrology referral for co-management (delineate responsibilities)
• Arm vein preservation
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