DIABETES AND THE KIDNEYS Benita S. Padilla, M.D.

How does diabetes affect the kidneys? About 20% of diabetics will develop diabetic nephropathy The glomeruli become deposited with abnormal proteins, leading to inflammation and scarring Diabetic nephropathy leads to progressive deterioration in kidney function Diabetic nephropathy is now the leading cause of ESRD in our country

Can we do anything to help our patients avoid developing diabetic nephropathy? YES!! Optimal blood sugar control Optimal blood pressure control

Can we do anything to help our patients who already have diabetic nephropathy? YES!! First, we must diagnose diabetic nephropathy at the earliest possible time -before the patient develops symptoms

How do we make an early diagnosis of diabetic nephropathy? All diabetic patients should be screened for MICROALBUMINURIA MICRO – small amount of ALBUMIN URIA – in the urine Defined as urine albumin between 30 and 300 mg/day

When should a diabetic be screened for MA? For patients with type 1 DM 5 years after initial diagnosis of DM, then annually thereafter For patients with type 2 DM upon initial diagnosis of DM, then annually thereafter

How should screening for MA be done? MA cannot be detected by the ordinary urinalysis A positive test for protein in the routine urinalysis means that the patient has macroalbuminuria already Macroalbuminuria is defined as albumin excretion more than 300 mg/day

To review: Microalbuminuria 30 to 300 mg/day Macroalbuminuria >300 mg/day

How should screening for MA be done? Routine urinalysis (+) Protein? YES Patient has MACROalbuminuria NO YES Patient has MICROalbuminuria Micral test positive? NO Repeat within 3 mos to confirm Repeat after 1 yr

Be meticulous about blood sugar control How can the onset and progression of diabetic nephropathy be prevented? Be meticulous about blood sugar control Goals: FPG < 120 mg/dl (6.7 mmol/L), HbA1c < 7%) Be meticulous about blood pressure control Goal: BP < 130/80 mm Hg Every 10 mm reduction in SBP reduces by 12% the risk of any complication due to DM!

Be careful with your choice of antihypertensive medications How can the onset and progression of diabetic nephropathy be prevented? Be careful with your choice of antihypertensive medications ACE inhibitors and ARBs are the drugs of choice in patients with DN Screen for microalbuminuria ACE inhibitors and ARBs are recommended even if the patient is not hypertensive

How can the onset and progression of diabetic nephropathy be prevented? Discourage smoking strongly Educate the patient

What are the late signs of diabetic nephropathy? Macroalbuminuria Difficult to control hypertension Edema, ascites Elevated BUN and creatinine

What are the late signs of diabetic nephropathy? Less need for anti-diabetic medications Nausea and vomiting Weakness and pallor

When should you refer a patient with diabetic nephropathy to a nephrologist? When albuminuria is first detected even if BUN and creatinine are normal!! Very important to intervene early to prevent progression to renal failure

Take home messsages Screening for microalbuminuria is the most effective way of detecting early diabetic nephropathy Early diagnosis is extremely important because it is possible to retard progression of renal disease

Take home messsages ACE inhibitors or angiotensin receptor blockers must be given in all patients with diabetic nephropathy!! You must think of the nephrologist not as someone you refer to because your patient has kidney failure but someone you refer to so that your patient will not develop kidney failure

Barangay, Municipal and District Level Screen all patients for diabetes All adults should have an FPG or casual plasma glucose every 2 years DM is diagnosed if FPG > 126 mg/dl (7 mmol/L) or CPG > 200 mg/dl (11.1 mmol/L), documented twice Refer all newly diagnosed diabetics for initial work-up Reinforce compliance with therapeutic lifestyle changes

Barangay, Municipal and District Level Monitor and encourage compliance with prescribed diabetic medications Monitor patient to check whether therapeutic goals are being achieved Refer patient if therapeutic goals are not achieved or patient develops new symptoms

Provincial Level Perform initial laboratory work-up recommended for all newly diagnosed diabetics Refer patients identified to have target organ damage to the appropriate specialist

Regional and Specialty Hospital Level Assess for presence of and severity of target organ damage For those with renal abnormalities, a nephrologist should formulate a management plan to improve renal status and/or prevent further kidney damage