Diabetes and Renal Disease

PACE guidelines for Diabetes 2002 Renal/Hypertension

Annual dipstick for protein Positive Negative Exclude UTI and quantify Urine for ACR All patients with diabetes have an annual check for proteinuria and serum creatinine

Proteinuria PCI –Maximum tolerated dose of ACEI PCI >1000 –Refer –ACE inhibitors

Albumin creatinine ratio > 2.5 on two occasions –ACE inhibitors at max tolerated dose All patients continue to have annual check for proteinuria

Serum Creatinine Check annually –>150 refer to renal If <150 but above normal range, needs earlier repeat

Key Points from the Guidelines Proteinuria/ microalbuminuria ACE Inhibitors Early referral –Creatinine (>150) –Proteinuria (PCI >1000)

The Nephrologists perspective The Final Common Pathway?

Late Referral Mrs W, age 62 NIDDM 20years CHF Obesity TKR Wheelchair bound ESRF at referral Prognosis

Late Referral Within < 4 months of starting dialysis many patients suffer a needlessly rough journey on the road to dialysis –Eadington Nephrol Dial Trans 1996

Late Referral QJM 2002 Bristol and Portsmouth % new RRT patients referred late Nearly half were avoidable late referrals Poorer clinical state at start of RRT and likely worse outcome

Late Referral Longer duration of predialysis nephrological care does improve outcome –Jungers et al 2001 How long is longer?

What are the benefits of earlier referral? or

The DOPPS Study To what extent does vascular access account for mortality on dialysis?

Late Referral in Bradford 13/35 new chronic HD patients referred late in 2001 Nephrologists are not blameless as only 8/35 commenced HD with a fistula Late referrals are more likely to be older, Asian and to have diabetes In all studies patients perceived as higher risk are referred late

Earlier referral should improve subsequent mortality/morbidity of patients with ESRF due to diabetes

Demographics Current take on rate in Bradford is approx 100 pmp Diabetes/hypertension/ESRF all more prevalent in South Asians Pending epidemic of type 2 diabetes DM 2x odds of death on dialysis cf non-diabetes Bradford dialysis cohort likely to double by 2010

Are we going to be able to dialyse our way out of trouble?

Or is there another way?

Is diabetic nephropathy preventable? Tight control Blood pressure Proteinuria ACE inhibitors Lipids Smoking cessation

Blood pressure and proteinuria Reducing blood pressure slows the rate of disease progression Superiority of ACE Inhibitors –Lewis et al NEJM 1993, Captopril Proteinuria is not just a disease marker but is pathogenetic Reduction in proteinuria slows progression –Reviewed in lancet editorial 1999, DeJong et al

Blood pressure and proteinuria Hovind Kidney International 2001 Normal progression of DN 10-12ml/min/year 7 year study of 300 type 1 patients 31% remission 22% regression (GFR decline 1ml/min/year) Even in this clinic many patients do not achieve BP targets

Glycaemic control Prevention of microalbuminuria (PDS, DCCT) Little evidence for beneficial effect on progression of established DN although did predict regression in the Hovind study Limits other complications Patients who cannot achieve tight control still benefit from BP treatment

Smoking and Lipids Meta-analysis suggests that lipid lowering can preserve GFR Renal function declines twice as fast in smokers –This is under appreciated by patients and doctors Progression, remission, regression of chronic renal disease Ruggenenti, lancet 2001: 357

This is not reversible 5.4cm

ESRF for average men and women Age60kg woman70kg man

Blood pressure

Blood Pressure Initiate therapy if BP > 140/80 Aim for 130/80 or lower Follow PACE hypertension guidelines

Anti-hypertensives in Diabetes Most patients will need several agents ACE inhibitors first line if ACR >2.5 Some contra-indications may be relative in diabetes Do not omit non-pharmacological measures

Blood pressure treatment in normotensives? Schrier et al, Kidney International /75 vs 137/81 Type 2 DM Reduced progression from normal to microalb to DN Reduced progression of retinopathy Reduced stroke

ACE Inhibitor guidelines Check creatinine prior to prescribing Check creatinine approx 10 days after 1st dose Re-check after any dose increase Omit in the presence of intercurrent illness especially if dehydration/hypotension Higher degree of vigilance if PVD or other reason to suspect renovascular disease

Any Questions?