1. Diabetes and the Kidney Richard Kingston Department of Renal Medicine Kent and Canterbury Hospital

2. King’s Guy’s Brighton Renal Services in Kent and East Sussex

3. http://www.britishrenal.org/CKD-Forum/Educational-Resources.aspx

7. 25.4%

9. 15.9%

13. x2 x3 x0.5

15. Diabetic Nephropathy – a Natural History (type II) 25% have microalbuminuria at time of diagnosis microalbuminuria develops in approximately 15% and proteinuria in 5% within 5 years 20% of microalbuminuric patients who survive for 10 years develop proteinuria, 50% remain microalbuminuric, 30% revert to normoalbuminuria Treated, proteinuric, hypertensive Type 2 diabetics lose glomerular function at the rate of approximately 8 ml/min/year. Individuals who survive for 10 years from diagnosis have an 8% risk of developing end stage renal failure.

17. Microalbuminuria Proteinuria Falling GFR Dialysis 10-20 yrs Stroke MI Amputation Blindness

18. The more ignorant, reckless and thoughtless a doctor is, the higher his reputation soars even amongst powerful princes.

19. http://cks.nice.org.uk/diabetes-type-2#!topicsummary

20. Assessment Renal function – Creatinine and eGFR Albuminuria – Albumin-Creatinine ratio – Microalbuminuria – Proteinuria Alternative diagnosis

21. Why is proteinuria a problem?

22. Assesment Renal function – Creatinine and eGFR Albuminuria – Albumin-Creatinine ratio – Microalbuminuria – Proteinuria Alternative diagnosis

23. Management Start ACE inhibitor Treat BP Control Blood Glucose Manage cardiovascular risk factors – BP <130/80 – Statin – Aspirin

25. Management Start ACE inhibitor Treat BP Control Blood Glucose Manage cardiovascular risk factors – BP <130/80 – Statin – Aspirin

28. RENAAL results - Primary components 2 Doubling of serum creatinine Months % with event p=0.006 Risk reduction: 25% 751692 583 329 52 762689 554 295 36 P (+ CT) L (+ CT) 012243648 0 10 20 30 P L

29. Mean BP and Rate of Decline in GFR in Diabetics and Non-Diabetics 9598101104107110113116119 r = 0.69; P < 0.05 MAP (mmHg) GFR (mL/min/year) 130/85140/90 Untreated HTN 0 -2 -4 -6 -8 -10 -12 -14 Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661.

30. Management Start ACE inhibitor Treat BP Control Blood Glucose Manage cardiovascular risk factors – BP <130/80 – Statin – Aspirin

31. Impact of Blood Pressure Reduction on Mortality in Diabetes Trial Conventional care Intensive care Risk reduction P-value UKPDS154/87144/8232%0.019 HOT144/85140/8166%0.016 Turner RC, et al. BMJ. 1998;317:703-713. Hansson L, et al. Lancet. 1998;351:1755–1762. Mortality endpoints are: UK Prospective Diabetes Study (UKPDS) – “diabetes related deaths” Hypertension Optimal Treatment (HOT) Study – “cardiovascular deaths” in diabetics

32. Diabetes: Tight Glucose vs Tight BP Control and CV Outcomes in UKPDS Stroke Any Diabetic Endpoint DM Deaths Microvascular Complications -50 -40 -30 -20 -10 0 % Reduction In Relative Risk Tight Glucose Control (Goal <6.0 mmol/l) Tight BP Control (Average 144/82 mmHg) 32% 37% 10% 32% 12% 24% 5% 44% * * * * *P <0.05 compared to tight glucose control

33. Summary Prevention Treat early and treat well It isn’t all about the Kidney Diabetics on dialysis need on-going support