1. William Vega-Ocasio MD. Internal Medicine - Nephrology
Centro Renal Hospital Menonita Cayey
Ext. 5503

2. The Dietitian Intervention
Diabetic Nephropathy
The Dietitian Intervention

3. Objectives Definition of Diabetic Nephropathy
Prevention and management of Diabetic Nephropathy
Nutritional Management of Diabetics with Advance Renal Disease

4. Overview Diabetes Mellitus
Disorder of impaired carbohydrates metabolism.
Either Insulin deficiency or Insulin resistant state.
Characterized by hyperglycemia (inadequate production or utilization of insulin).
Multi systemic organ damage : eyes, nerves, blood vessels, heart and kidneys.

6. Overview Diabetes Mellitus
Advance glycosylation of tissue proteins (AGEP)
Irreversible glycosylation of Hemoglobin
Microvascular damage ( nephropathy & retinopathy)
Renal and Cardiovascular complications
Direct effect in Lipid metabolism

7. Diabetic Nephropathy
Leading cause of and contributor to End Stage Renal Disease “ESRD” (CKD V)
Development is related to duration of diabetes and degree of hyperglycemia
Progresses in stages to CKD V if not treated

8. Diabetic Nephropathy Occurs in both DM Type I & II
Peak incidence of disease for Type I diabetics is between years after onset of disease
Usually already present for those diagnosed with Type II Diabetes

9. Diabetic Nephropathy
HEART
VASCULAR SYSTEM
KIDNEY

10. Diabetic Nephropathy Characterized : Microvacular damage to kidney
Earliest clinical evidence is appearance of microalbuminuria (incipient nephropathy)
Slowly progressive disorder
Untreated will result in massive protein excretion and decreased glomerular filtration rate (↓ GFR)

11. Untreated Diabetic Nephropathy

12. Diabetic Nephropathy
Hyperglycemia
Nephropathy
ESRD

13. Diabetic Nephropathy STAGE GFR URINE PROTEIN BP
I. Hyperfiltration Super normal <30mg/day Normal
II. Micro- Alb High-Normal mg/day Rising
III. Proteinuria Normal-Decreasing <300mg/day Elevated
IV. Nephropathy Decreasing Increasing Elevated
V. ESRD <15mL/min Massive Elevated
National Kidney Foundation “Primer on Kidney Diseases” Fourth edition Elsevier Saunders

14. From EdREN, the website of the Renal Unit of the Royal Infirmary of Edinburgh

15. Diabetic Nephropathy Stage I
Stage I-A
Increased Kidney Filtration
Osmotic load and Toxic effects of hyperglycemia
Increased Glomerular Filtration Rate
Kidney enlargement
Stage I-B
Silent Phase
Hyperfiltration
Hypertrophy
Increased production of inflammatory mediators

16. Diabetic Nephropathy Stage II
Microalbuminuria (30-300mg/day)
Basement membrane thickening due to AGEP’s
Increased Microvascular damage
Cardiovascular disease and retinopathy
20% risk of nephropathy within 5 years with standard care
Glomerular Filtration Rate not markedly affected, but kidney inflammatory damage

17. Diabetic Nephropathy Stage III
Proteinuria (>300mg/day)
Decreased Glomerular filtration Rate
Severe protein wasting with it complications
Up to 10% of patients may excrete
< 3000mg/day
Systemic microvascular and cardiovascular disease complications
Abnormal lipid metabolism (Cholesterol & Triglycerides)

18. Diabetic Nephropathy Stage IV
Prepare for Treatment
Progressive nephropathy
Markedly decreased GFR
Signs and Symptoms of Protein Calorie malnutrition
Advance Retinopathy
Cardiovascular catastrophes
Cerebrovascular catastrophes

19. Diabetic Nephropathy Stage V
End Stage Renal Disease (CKD V)
Renal Replacement therapy
Severe protein calorie malnutrition
Severe peripherovasclular disease
Cerebrovascular Disease
Cardiovascular Disease
Infections

20. Objectives Definition of Diabetic Nephropathy
Prevention and management of Diabetic Nephropathy
Nutritional Management of Diabetics with advance Renal Disease

21. Progression of Disease
Diabetic Nephropathy
Hyperglycemia
Nephropathy
ESRD
Progression of Disease
Regression of Disease

22. National Kidney Foundation

23. Diabetic Nephropathy Stages of CKD I : Above normal GFR
II : Glomerular Damage, Microalbuminuria (30-300mg/day)
III : Proteinuria (>300mg/day),Hypertension
IV : More Glomerular Damage, Increasing Proteinuria, Decreased GFR → Azotemia
V : GFR < 15ml/min/1.73m2 → Renal Replacement Therapy

24. From Chronic Kidney Disease, Dialysis, and Transplantation, Second Edition, Elsevier Saunders 2005

25. From Chronic Kidney Disease, Dialysis, and Transplantation, Second Edition, Elsevier Saunders 2005

26. Prevention or Regression of Disease

27. Prevention or Regression of Disease
Glycemic Control
Hypertension Control
Control Microalbuminuria or Proteinuria
Dietary Protein Restriction*
Treatment of Dyslipidemias

28. Diabetic Nephropathy Glycemic Control
Partially reverse glomerular hypertrophy and hyperfiltration
Delay development of microalbuminuria
Delay the onset or progression of nephropathy
Delay onset of microvascular damage to organs

29. Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

30. Diabetic Nephropathy Hypertension Control
Single most effective measure for delaying progression of Chronic Kidney Disease
Aggressive treatment is able to decrease the rate of Diabetic Nephropathy Progression
Reduce microvascular cardiac, retinal and systemic complications
Goal BP Target ≤ 130/85 in diabetics
Goal BP Target ≤ 125/75 in nephropathy

31. Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

32. Diabetic Nephropathy Antihypertensive Agents
Angiotensin converting enzyme inhibitors (ACE)
Angiotensin Receptor Blocker (ARB)
Calcium Channel Blocker (CCB)
Diuretics ( Loop and Thiazides )
β – Blockers
α – Blockers

33. Diabetic Nephropathy Control Microalbuminuria or Proteinuria
Untreated will accelerate the progression of diabetic nephropathy
ACE inhibitors delay progression of nephropathy in Type I DM
ACE inhibitors and ARB’s delay progression from microalbuminuria to proteinuria In Type II DM
ARB’s delay progression to nephropathy in
Type II DM with HTN and CKD

34. Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

35. Diabetic Nephropathy Dietary Protein Restriction Careful Restriction
Not all patients are candidates
Helps by reducing hyperfiltration
Helps by reducing intraglomerular pressure
Retards progression of renal disease
Recommendations grams per kilogram of body weight a day

36. Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes

37. STOP !!!

38. Diabetic Nephropathy Protein Restriction ? Proteinuria :
Loss of Immunoglobulins
Loss of lipoproteins
Loss of tissue regeneration proteins
Protein Calorie Malnutrition
Protein Restriction ?

40. Diabetic Nephropathy
…low protein diets may actually harm this population, primarily by aggravating malnutrition….

41. Diabetic Nephropathy
…there is suggestive clinical and experimental evidence that dietary protein restriction may be ineffective in CKD patients receiving standard anti-proteinuric therapy with ACE inhibitors or ARB’s.

42. Diabetic Nephropathy
…low protein diets are associated with both statistically and clinically significant declines in nutritional markers in CKD populations, in whom the prevalence of malnutrition is 50%.

44. Diabetic Nephropathy Treatment of Dyslipidemias
Important in prevention of atherosclerosis
Reductase inhibitors (Statins) may protect against glomerulosclerosis
ADA Goals for Lipids:
LDL ≤ 100 mg/dL
HDL ≥ 40 mg/dL

45. Objectives Definition of Diabetic Nephropathy
Prevention and management of Diabetic Nephropathy
Nutritional Management of Diabetics with advance Renal Disease

46. Levey, A. S. et. al. Ann Intern Med 2003;139:137-147
Evidence model for stages in the initiation and progression of chronic kidney disease (CKD) and therapeutic interventions
Levey, A. S. et. al. Ann Intern Med 2003;139:

47. Diabetic Nephropathy Management Early stages ( I & II) :
Strict Glycemic control !!!
Potassium Restriction
Treatment of dyslipidemias
Sodium Restriction
Remove Irritants from diet
Nutritional Supplements ( FA, Iron, etc..)
Family support Plan

48. Diabetic Nephropathy Management Advanced stages ( III & IV) :
Glycemic control, avoid hypoglycemia !!!
Potassium Restriction !!!
Phosphorus Restriction
Treatment of dyslipidemias
Sodium Removal from diet
Remove Irritants from diet
Nutritional Supplements ( FA, Iron, etc..)
Prepare for Treatment

50. Summary Early referral is essential !!!
Work with your nephrologists or endocrinologist
Identify, treat and prevent malnutrition
Know your patients medications
Join educational efforts

51. Thank You !!!