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

2. 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

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

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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!

11. 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

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

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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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