Diabetes. The leading cause of kidney failure in the US Type 1 diabetes- screened at five years of. disease duration or at the onset of puberty …
Diabetic Nephropathy
Wisconsin Diabetes Essential Care Guidelines: Kidney Care
Jonathan B Jaffery, MD University of Wisconsin Medical School Department of Medicine, Nephrology Section
World Kidney Day March 13, 2008
Diabetes
The leading cause of kidney failure in the US Diabetic nephropathy 20-40 of people with diabetes Without intervention: progress to ESRD 5-7 years Main influences on progression: glycemic control and BP Microalbuminuria confers twice the risk of progression
Screening for Kidney Disease and Interpreting the Results
Typical Disease Course:
Microalbuminuria small amounts of albumin Macroalbuminuria large amounts of albumin loss of kidney function and ESRD
Screening:
Type 2 diabetes- screened for microalbuminuria at the time of diagnosis and annually thereafter Type 1 diabetes- screened at five years of disease duration or at the onset of puberty whichever occurs first and annually thereafter
Screening for Kidney Disease and Interpreting the Results
More frequent screening may be indicated for certain groups:
Family history of kidney disease and/or Htn History of poor glycemic control African American, Hispanic, American Indian
Albumin
excretion can vary day to day and can be affected by other factors uncontrolled BP, high blood glucose, fever, UTI, physical activity Therefore recommended that elevated values be confirmed over 3 6 months before microalbuminuria is definitively diagnosed
Screening for Kidney Disease and Interpreting the Results
A routine UA for protein is not sensitive enough to detect microalbuminuria and is therefore not an appropriate test for early detection of diabetic kidney disease
Condition
Normal Microalbuminuria Macroalbuminuria
Value
30 mg/g 30-300 mg/g 300 mg/g
Screening for Kidney Disease and Interpreting the Results
Once a person has an albumin/creatinine ratio of 300 mg/g macroalbuminuria, urine protein excretion can be followed using the protein/creatinine ratio The protein/creatinine ratio is measured from a random urine sample and can be used to follow progression of kidney disease and response to therapy 24-hour urine collections for protein excretion are not needed, and wasteful
Further Evaluation of Kidney DiseaseEstimating GFR
An estimated Glomerular Filtration Rate eGFR, calculated from a serum creatinine is also recommended yearly in all adults with
diabetes regardless of the degree of urine albumin excretion A substantial percentage of adults with diabetes have been found to have decreased eGFR in the absence of increased urine albumin
Further Evaluation of Kidney Disease- Estimating GFR
Calculating eGFR: The Modification of Diet in Renal Disease MDRD Study equation uses only serum creatinine, age, gender, and race
While the MDRD Study equation requires a calculator with exponential functions, multiple online resources provide a calculator that estimates GFR:
http://wwwkidneyorg/professionals/kdoqi/gfr_calculatorcfm
Also, many labs now automatically report eGFR with serum creatinine values
Further Evaluation of Kidney Disease- staging
Chronic kidney disease CKD should be staged according to the level of estimated GFR Based on the level of estimated GFR, individuals can be placed into one of 5 stages
K/DOQI guidelines, AJKD, Vol 39, No 2, Suppl 1, February 2002
This is helpful in designing a clinical action plan
Further Evaluation of Kidney Disease- Estimating GFR
The MDRD equation is most a 
ccurate for individuals with estimated GFRs 60 ml/min/173 m2 stage 3 chronic kidney disease and higher 24-hour urine
collections for creatinine clearance are not needed, and wasteful A serum creatinine alone should not be used to estimate kidney function
Using serum creatinine to guess level of renal function
24-yo Black Man SCr GFR as estimated by MDRD Study equation 13 mg/dL 63-yo White Man 13 mg/dL 59-yo White Woman 13 mg/dL
60 mL/min/173 m2
59 mL/min/173 m2
45 mL/min/173 m2
Stages of CKD A Clinical Action Plan
CKD Stage Stage 1: Kidney damage normal or GFR Stage 2: mild GFR Stage 3: Moderate GFR Stage 4: Severe GFR GFR 90 60-89 30-59 15-29 15 Action including action from preceding stages Diagnosis/treatment of underlying cause, comorbid conditions Slowing progression Cardiovascular disease risk reduction Estimate progression Evaluating and treating complications Consider referral to a nephrologist Preparation for RRT Referral to a nephrologist Referral for transplantation Renal replacement therapy
Stage 5: Kidney failure
Management of Kidney Disease
Angiotensin-coverting Enzyme inhibitors ACEi or Angiotensin Receptor Blockers ARBs slow progression of diabetic kidney disease independent of their effect on lowering blood pressure The most common side effects early
decrease in GFR, hypotension, and hyperkalemia can usually be managed without discontinuation of the agent With careful monitoring of therapy, most people, even those with low levels of GFR, can be treated
Management of Kidney Disease
In addition to ACEi/ARB, aggressive BP control is key Most people will require more than one agent to obtain the BP goal of 130/80 mmHg If not at goal, other agents should be added eg, diuretics, beta-blockers, calcium channel blockers, or sympathetic antagonists Note: ACEi/ARB therapy should not be prescribed to women of childbearing age not using contraception or to pregnant women
Referral to a Nephrologist and Coordination of Care
Caring for people with kidney disease is challenging Early intervention and timely referrals for consultation with kidney experts and other specialty services can lead to optimal management of diabetes and kidney disease Nephrology referral is recommended in the following circumstances:
The estimated GFR is less than 30 ml/min/173 m2 Loss of kidney function is rapid ie, greater than 10-15 ml/min/year The blood pressure target cannot be achieved For assistance in carrying out the clinical action
plan
Essential Patient Education for Kidney Disease
Education may include, but is not limited to, the following:
Glycemic control is essential to prevent or slow progression of diabetic kidney disease Annual kidney function testing and appropriate follow-up are necessary People in early stages of decreased kidney function are typically asymptomatic
Essential Patient Education for Kidney Disease
Hypertension plays a major role in kidney disease and should be treated aggressivelymultiple medications are common for most people Lifestyle modifications are important in delaying or slowing the progression of kidney disease The importance of kidney function tests Benefits of early referral to a nephrologist for declining estimated GFR and what to expect from the visit
Wisconsin Diabetes Essential Care Guidelines
New Updates expected Order the 2008 Version Now
Source:gorbzilla.com
