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William Vega-Ocasio MD. Internal Medicine - Nephrology Centro Renal Hospital Menonita Cayey 787-535-1001 Ext. 5503

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Presentation on theme: "William Vega-Ocasio MD. Internal Medicine - Nephrology Centro Renal Hospital Menonita Cayey 787-535-1001 Ext. 5503"— Presentation transcript:

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

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

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

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

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

9 Diabetic Nephropathy Carbohydrates Load Insulin Deficiency Hyperglycemia Increased Transforming Growth factor Angiotensin Platelet Derived Growth factor Abnormally Regulated Thromboxanes and Endothelins Microvascular Damage HEART VASCULAR SYSTEM KIDNEY

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

11 Untreated Diabetic Nephropathy

12 Diabetic Nephropathy Hyperglycemia Hyperglycemia Nephropathy Nephropathy ESRD ESRD

13 Diabetic Nephropathy STAGE GFR URINE PROTEIN BP 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 EdinburghEdREN

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

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

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

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

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

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

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

22 National Kidney Foundation

23 Diabetic Nephropathy Stages of CKD Stages of CKD I : Above normal GFR I : Above normal GFR II : Glomerular Damage, Microalbuminuria (30-300mg/day) II : Glomerular Damage, Microalbuminuria (30-300mg/day) III : Proteinuria (>300mg/day),Hypertension III : Proteinuria (>300mg/day),Hypertension IV : More Glomerular Damage, Increasing Proteinuria, Decreased GFR Azotemia IV : More Glomerular Damage, Increasing Proteinuria, Decreased GFR Azotemia V : GFR < 15ml/min/1.73m 2 Renal Replacement Therapy V : GFR < 15ml/min/1.73m 2 Renal Replacement Therapy

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

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26 Prevention or Regression of Disease

27 Glycemic Control Glycemic Control Hypertension Control Hypertension Control Control Microalbuminuria or Proteinuria Control Microalbuminuria or Proteinuria Dietary Protein Restriction* Dietary Protein Restriction* Treatment of Dyslipidemias Treatment of Dyslipidemias

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

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

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

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

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

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

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

35 Diabetic Nephropathy Dietary Protein Restriction Dietary Protein Restriction Careful Restriction Careful Restriction Not all patients are candidates Not all patients are candidates Helps by reducing hyperfiltration Helps by reducing hyperfiltration Helps by reducing intraglomerular pressure Helps by reducing intraglomerular pressure Retards progression of renal disease Retards progression of renal disease Recommendations grams per kilogram of body weight a day 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 Proteinuria : Proteinuria : Loss of Immunoglobulins Loss of Immunoglobulins Loss of lipoproteins Loss of lipoproteins Loss of tissue regeneration proteins Loss of tissue regeneration proteins Protein Calorie Malnutrition Protein Calorie Malnutrition Protein Restriction ?

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

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%. …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%.

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44 Diabetic Nephropathy Treatment of Dyslipidemias Treatment of Dyslipidemias Important in prevention of atherosclerosis Important in prevention of atherosclerosis Reductase inhibitors (Statins) may protect against glomerulosclerosis Reductase inhibitors (Statins) may protect against glomerulosclerosis ADA Goals for Lipids: ADA Goals for Lipids: LDL 100 mg/dLLDL 100 mg/dL HDL 40 mg/dLHDL 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: Evidence model for stages in the initiation and progression of chronic kidney disease (CKD) and therapeutic interventions

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

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

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

51 Thank You !!!


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