1. Diabetes And Hemodialysis 1 Dr.Ruba Nashawati

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3. DM+CKD Renal Care + Dialysis 3

4. Type 2 + CKD  Nephrologist ASAP Death is Cardiac ≈ ½ Dead patient Survival DM +HD < Other +HD 4

5. Renal disease Diabetic Nephropathy Hypertensive Vascular Disease Glomerular Tubulointerstitial 5

6. Symptoms Of Kidney Disease Fluid retention (Oedema legs/face ) Fatigue Headache Nausea Vomiting BY INCIDENCE BY INCIDENCE 6

7. Therapeutic goal In Stage 3-5 CKD 1. Treatment of complications 2. Aggressive therapy of coexisting disease (CVD) 3. Correct choice of Renal Replacement Therapy (RRT) 7

8. Metabolic Control 8

9. Glucose Control 1. Insulin Resistance  Insulin requirements 2. HD  Insulin requirements 20% 9

10. Glucose Control Diabetes “CURED” /Advancing CKD 1. Reduced appetite and CHO intake 2. Prolonged insulin half-life 3. False elevation of HbA1c by 0.5-1% 10

11. Glucose Control Recommend  Insulin Dose50-70% (non-Dialytic) HBA1c 7-7.5 % 11

12. Glucose Control We recommend a target hemoglobin A1c (HbA1c) of B7.0% (53 mmol/mol) to prevent or delay progression of the microvascular complications of diabetes, including diabetic kidney disease. 12

13. Glucose Control We recommend not treating to an HbA1c target of 7.0% (53 mmol/mol) in patients at risk of hypoglycemia. 13

14. Glucose Control We suggest that target HbA1c be extended above 7.0% (53mmol/mol) in individuals with comorbidities or limited life expectancy and risk of hypoglycemia. 14

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16. Blood pressure Target 130/80 mmHg ACEi /ARBS B-Blocker Loop Diuretics 16

17. Lipid Control 1 st choice  statin 17

18. Lipid Control 18 GFR <30Max dose Atorvastatin80mg/dl Fluvastatin80mg/dl Pravastatin10mg/dl Simvastatin20mg/dl Rosovastatin10mg/dl EzitimibeSafe

19. Diet We suggest lowering protein intake to 0.8 g/kg/day in adults with diabetes or without diabetes and GFR 30 ml/min/ 1.73 m2 (GFR categories G4-G5), with appropriate education 19

20. Diet We suggest avoiding high protein intake (41.3 g/kg/day) in adults with CKD at risk of progression 20

21. Anemia Occur Early Sever Usually  Cardiac Death Treat With Erythropoietin Studies  High Doses Than Non Diabetics 21

22. Minerals And Bone We recommend measuring serum levels of calcium,phosphate, PTH, and alkaline phosphatase activity at least once in adults with GFR 45 ml/min/1.73 m2 22

23. Minerals And Bone GFR categories (G3b-G5) in order to determine baseline values and inform prediction equations if used. 23

24. Minerals And Bone In people with GFR 45 ml/min/1.73m2 GFR categories (G3b-G5), we suggest maintaining serum phosphate concentrations in the normal range according to local laboratory reference values. 24

25. Minerals And Bone In people with GFR 45 ml/min/1.73m2 GFR categories (G3b-G5) the optimal PTH level is not known. 25

26. Minerals And Bone We suggest that people with levels of intact PTH above the upper normal limit of the assay are first evaluated for hyperphosphatemia, hypocalcaemia, and vitamin D deficiency. 26

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28. Renal Replacement Therapy 28

29. Hemodialysis 29

30. Peritoneal Dialysis 30

31. Renal Transplantation 31

32. Choice of a Dialysis modality Choice of a Dialysis modality modality modality 1. Comorbid conditions 2. Home situation 3. Independence and motivation of the patient. 4. Ability to tolerate volume shifts (hypotensive) 5. Status of the vascular/ abdomen 6. Risk of infection 32

33. Choice of a Dialysis modality 1. No preference for HD over PD 2. Young Tx is over HD 3. Prepare as early as possible 4. Diabetics will ESRD of all ages benefit from kidney transplantation 5. Type1 =benefit +pancreas transplantation 33

34. When to start If One or more are present 34

35. When to start 1. Symptoms or signs of CKD 2. Electrolyte abnormalities/pruritus 3. Inability to control volume status /blood pressure 4. Progressive deterioration in nutritional status; or cognitive impairment Usually GFR 5-10 5. Diabetics tolerate less so GFR 10-15 even 20 35

36. Vascular Acces Difficult vascular access Frequent sepsis 36

37. Vascular Acces Arterio-venous (AV) Fistula PTFE Graft Temporary catheters “Permanent” catheters 37

38. Diabetes and ESKD Reducing insulin requirements Difficult vascular access Accelerated macrovascular disease Advanced microvascular disease Frequent sepsis Silent ischaemia 2-3 x death rate vs non-DM patients 38

39. 39 Temporary Catheters

40. “Permanent” catheters 40

41. 41 PTFE Graft

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43. Non Renal Complication In Diabetics That keep Progression 43

44. 1. Cardiac Arterial Disease 2. Retinopathy 3. Cataract 4. Cerebrovascular Disease 5. Peripheral Vascular Disease 44

45. 1. Autoimmune Neuropathy 2. Peripheral Neuropathy 3. Sexual Dysfunction 4. Depression 45

46. Problems Due To DM On HD 46

47. Silent ischaemia  regular consultation Gastroparesis  metoclopramide Blood glucose control Insulin requirements  PD  HD Hypotension ≈ Autonomic neuropathy  UF rate / Hb / Na profile 47

48. Vascular disease Difficult to get vascular access Steal syndrome Retinopathy Infection  special care for accesses Impotence 48

49. Q. Which features are typical of diabetic CKD at presentation ? Haematuria NO Small scarred kidneys NO Progress to ESKD in <2yrs NO Associated retinopathy YES  -blockers better than ACE-I Rx NO 49

50. At The End 50

51. Although the development and progression of Diabetic Nephropathy may be retarded by normalization HTN (ACEi/ARBs) and strict control of the plasma glucose concentration, many patients still progress to ESRD 51

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