Diabetic Nephropathy
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Transcript of Diabetic Nephropathy
04/09/2023 1
DIABETIC NEPHROPATHY
Upendra Reddy. K
2010H146037H
04/09/2023 2
Diabetes has become the most common single cause of end-stage renal disease (ESRD).
Accounts for over one-third of all patients who are on dialysis.
About 20–30% of patients with type 1 or type 2 diabetes develop evidence of nephropathy.
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Epidemiology
Type 1 Diabetic 25 - 45% will develop diabetic nephropathy 80 - 90% with micro albuminuria will
progress to overt diabetic nephropathy in 5 - 10 years
nearly 100% with gross proteinuria will progress to ESRD in 7 - 10 yrs
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Epidemiology
Type 2 Diabetic
50% will have micro albuminuria at the time of presentation with hypertension
10-20% with micro albuminuria will progress to overt nephropathy.
Minority populations have a 2 to 20-fold higher incidence of diabetic nephropathy.
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Risk Factors:
Age, Race, Ethnicity (native Americans, Mexican Americans,
African Americans) History of micro albuminuria Hypertension Poor glycemic control Smoking Family history of nephropathy.
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Stage I – Hyper filtration - increased blood flow through the kidney, early renal hypertrophy
Stage II - Glomerular lesions without clinically evident disease
Stage III - Incipient nephropathy with micro albuminuria - alb/cr ratio .03 - .3 or albumin 20-200 mcg/min on timed specimen
Stages of Diabetic Nephropathy
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Stages of Diabetic Nephropathy
020406080
100120140160180
0 5 10 15 20 25 30
Duration of Diabetes
GF
R
III III
IV
V
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Stage IV - Overt diabetic nephropathy with proteinuria >500 mg/24 hr creatinine clearance <70 ml/min
Stage V – End stage renal disease (ESRD)
- creatinine clearance <15 ml/min - creatinine = 6mg/dl
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Signs & symptoms:
Fatigue
Protein in urine
Foamy appearance/excessive frothing of urine
Frequent hiccups
Swelling of the legs
Unintentional weight gain(from fluid build up)
Diabetic nephropathy :Diagnosis & treatment
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Screening for micro albuminuria:
I. Measurement of the albumin-to-
creatinine ratio in a random spot
collection;
II. 24-h collection with creatinine,
allowing the simultaneous
measurement of creatinine
clearance;
III. Timed (e.g., 4-h or overnight)
collection.
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SCREENING FOR NEPHROPATHYWHEN: Type 1 - annually after puberty and 5 years of DM
Type 2 - at diagnosis and then annually
WHAT: random urine ACR;
and random urine dipstick
Normal< 2.0 mg/mmol men
< 2.8 mg/mmol womenRescreen in 1 year
Microalbuminuria2.0 - 20 mg/mmol men
2.8 - 28 mg/mmol women
Macroalbuminuria> 20 mg/mmol men
> 28 mg/mmol womenDiabetic nephropathy
diagnosed
Up to 2 repeat random urine ACRs performed 1 week to 2
months apart
Suspicion of nondiabetic
renal disease?
Yes
Workup or referral fornondiabetic renal
diseaseNo
Check ACR results
Only 1 abnormal ACR: Repeat screen
in 1 year
Any 2 abnormal out of 3 ACRs: Diabetic
nephropathy diagnosed
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Treatment of Diabetic Nephropathy
Hypertension Control - Goal: lower blood pressure to <130/80 mmHg
ACE inhibitors: captopril, enalapril, lisinopril, benazepril, fosinopril,
ramipril, quinapril, perindopril, trandolapril, moexipril
Angiotensin receptor blockers(ARB) candesartan cilexetil, irbesartan, losartan potassium,
telmisartan, valsartan, esprosartan
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Treatment of Nephropathy:
Patients starting therapy with an ACE inhibitor or ARB should be monitored at 1 to 2 weeks for significant worsening of kidney function or the development of significant hyperkalemia. Serum creatinine typically rises up to 30% above baseline after initiating an ACE inhibitor or ARB, and usually stabilizes after 2 to 4 weeks.
Patients who develop mild to moderate hyperkalemia should receive nutritional counseling regarding a potassium-sparing diet and consideration should be given to the use of non-potassium-sparing diuretics.
TREATMENT
Treatment group Preferred agent
Type 1 diabetes ACE inhibitor
Type 2 diabetes Cr Cl > 60 mL/min Cr Cl < 60 mL/min
ACE inhibitor or ARBARB
Second-line renal protective agents (non-dihydropyridine calcium channel blockers) can be considered in those unable to tolerate an ACE inhibitor or an ARB.
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TREATMENT OF NEPHROPATHY
Already on ACE inhibitor?
Choose 2nd line therapy: ACE +ARB or add non-DHP CCB
NO
On first-line nephropathydrug?
NO
First line drug atmaximum dose?
YES
Add first-line drug;Recheck ACR in 2 weeks to 2 months
ACR normal?
First line drugs:Type 1- ACE inhibitorType 2 with Cr Cl > 60 mL/min - ACE inhibitor or ARBType 2 with Cr Cl 60 mL/min - ARB
Titrate up; recheck ACR in
2 weeks to 2 months
YES
Yes Remeasure ACR in 1 year
NONO
YES
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Ongoing clinical trials:
Drug Clinical trial phase
Company Last updated
LY2382770 Phase-II Eli Lilly March 14,2011
PH3 Phase-II Phytohealth corporation
Jan 4, 2011
N-acetyl cystein
Phase-II The university of Texas health science
Sep 17 ,2010
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References: American Diabetes Association. Standards of medical care
in diabetes--2010. Diabetes Care. 2010 Jan;33 Suppl 1:S11-61
American Diabetes Association (2004). Nephropathy in diabetes. Clinical Practice Recommendations 2004. Diabetes Care. 27(Suppl 1): S79–S83
DeFronzo RA: Diabetic nephropathy: etiologic and therapeutic considerations. Diabetes Reviews 3:510-547, 1995
www.clinicaltrials.gov.in