Diabetic Nephropathy

 Over 40% of new cases of end-stage renal disease (ESRD) are attributed to diabetes.  In 2001, 41,312 people with diabetes began treatment for end-stage renal disease.  In 2001, it cost $22.8 billion in public and private funds to treat patients with kidney failure.  Minorities experience higher than average rates of nephropathy and kidney disease

Five Stages of Kidney Disease Stage 1: Hyperfiltration, or an increase in glomerular filtration rate (GFR) occurs. Kidneys increase in size. Stage 2: Glomeruli begin to show damage and microalbuminurea occurs. Stage 3: Albumin excretion rate (AER) exceeds 200 micrograms/minute, and blood levels of creatinine and urea- nitrogen rise. Blood pressure may rise during this stage.

Five Stages of Kidney Disease (con’t.) Stage 4: GFR decreases to less than 75 ml/min, large amounts of protein pass into the urine, and high blood pressure almost always occurs. Levels of creatinine and urea-nitrogen in the blood rise further. Stage 5: Kidney failure, or end stage renal disease (ESRD). GFR is less than 10 ml/min. The average length of time to progress from Stage 1 to Stage 4 kidney disease is 17 years for a person with type 1 diabetes. The average length of time to progress to Stage 5, kidney failure, is 23 years.

Screening for Diabetic Nephropathy 1 American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004

Treatment of Diabetic Nephropathy Hypertension Control - Goal: lower blood pressure to <130/80 mmHg –Antihypertensive agents Angiotensin-converting enzyme (ACE) inhibitors –captopril, enalapril, lisinopril, benazepril, fosinopril, ramipril, quinapril, perindopril, trandolapril, moexipril Angiotensin receptor blocker (ARB) therapy –candesartan cilexetil, irbesartan, losartan potassium, telmisartan, valsartan, esprosartan Beta-blockers

Glycemic Control –Preprandial plasma glucose mg/dl –A1C <7.0% –Peak postprandial plasma glucose <180 mg/dl –Self-monitoring of blood glucose (SMBG) –Medical Nutrition Therapy Restrict dietary protein to RDA of 0.8 g/kg body weight per day Treatment of Diabetic Nephropathy (cont.)

Treatment of End-Stage Renal Disease (ESRD) There are three primary treatment options for individuals who experience ESRD: 1. Hemodialysis 2. Peritoneal Dialysis 3. Kidney Transplantation

Hemodialysis Procedure –A fistula or graft is created to access the bloodstream –Wastes, excess water, and salt are removed from blood using a dialyzer –Hemodialysis required approx. 3 times per week, each treatment lasting 3-5 hrs –Can be performed at a medical facility or at home with appropriate patient training

Hemodialysis Diet –Monitor protein intake –Limit potassium intake –Limit fluid intake –Avoid salt –Limit phosphorus intake Complications –Infection at access site –Clotting, poor blood flow –Hypotension Hemodialysis (cont.)

Peritoneal Dialysis Procedure –Dialysis solution is transported into the abdomen through a permanent catheter where it draws wastes and excess water from peritoneal blood vessels. The solution is then drained from the abdomen. –Three Types of Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycler-Assisted Peritoneal Dialysis (CCPD) Combination CAPD and CCPD

Peritoneal Dialysis (cont.) Peritoneal Dialysis Diet –Limit salt and fluid intake –Consume more protein –Some potassium restrictions –Reduce caloric intake Complications –Peritonitis

Kidney Transplant Procedure –A cadaveric kidney or kidney from a related or non-related living donor is surgically placed into the lower abdomen. –Three factors must be taken into consideration to determine kidney/recipient match: Blood type Human leukocyte antigens (HLAs) Cross-matching antigens

Kidney Transplant (cont.) Kidney Transplant Diet –Reduce caloric intake –Reduce salt intake Complications/Risk Factors –Rejection –Immunosuppressant side effects Benefits –No need for dialysis –fewer dietary restrictions –higher chance of living longer

How Can You Prevent Diabetic Kidney Disease? Maintain blood pressure <130/80 mm/Hg Maintain preprandial plasma glucose mg/dl Maintain postprandial plasma glucose <180 mg/dl Maintain A1C <7.0%

References American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004 National Kidney and Urologic Diseases Information Clearinghouse. Kidney Disease of Diabetes. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; United States Renal Data System. USRDS 2003 Annual Data Report. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; DeFronzo RA: Diabetic nephropathy: etiologic and therapeutic considerations. Diabetes Reviews 3: , 1995 National Kidney and Urologic Diseases Information Clearinghouse. Kidney Failure: Choosing a Treatment That’s Right For You. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003.