Albuminuria in Diabetic Patients

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nephrology

Text of Albuminuria in Diabetic Patients

  • MICHEL JADOUL

    Disclosure of Interest

    Scientific advice to companies:

    Amgen, ZS-Pharma, Fresenius, Sanofi, Shire, Amgen,

    Menarini

    Travel refunds, congress registration fees:

    Amgen

    Research grant:

    Amgen, Baxter, Fresenius, Janssen-Cilag, Roche

    The details of each Disclosure of Interest are available at the Invited Speakers desk (located in the Registration Area).

  • Professor Michel JadoulCliniques Universitaires St. LucUniversit Catholique de LouvainBrussels, Belgium

    Albuminuria in diabetic patients : prognosis and management

  • Albuminuria in diabetics

    Prognostic impact of albuminuria in generaland in diabetics

    Is albuminuria measured in T2D?

    How should albuminuria best be managed?

  • Prognostic value of GFR and albuminuria:

    Cohorts and Subjects of CKD Consortium

    Community based populations With ACR data, 14 studies, n=105,872

    With dipstick data, 10 studies, n=1,239,447

    Populations at increased CVD risk (HTN, diab, CV) 10 studies, n=266,975

    CKD cohorts 14 studies, n= 21,688

    45 cohorts in total, >1.5 million subjects

    Collaborative meta-analysis

    Major publications: Lancet, KI, JAMA

  • Prognostic value of GFR and albuminuria:

    Cohorts and Subjects of CKD Consortium

    Community based populations With ACR data, 14 studies, n=105,872

    With dipstick data, 10 studies, n=1,239,447

    Populations at increased CVD risk (HTN, diab, CV) 10 studies, n=266,975

    CKD cohorts 14 studies, n= 21,688

    45 cohorts in total, >1.5 million subjects

    Collaborative meta-analysis

    Major publications: Lancet, KI, JAMA

    Matsushita et al, Lancet 2010

  • Adjusted relative risk of renal and cardiovascular outcomes

    for GP cohorts with ACR

    Levey et al, Kidney Int 2011

  • Cause GFR Categories

    (ml/min/1.73m2)

    Albuminuria Categories

    (ACR, mg/g)

    Diabetes G1 90 A1

  • Dialysis or serum creat X2

  • Albuminuria in diabetics

    Prognostic impact of albuminuria in generaland in diabetics

    Is albuminuria measured in T2D?

    How should albuminuria best be managed?

  • 75.6 % of pts with T2D have a urine test for albuminuria within the 1st year after startingantidiabetic medication

  • Albuminuria in diabetics

    Prognostic impact of albuminuria in generaland in diabetics

    Is albuminuria measured in T2D?

    How should albuminuria best be managedwith currently available (registered) drugs?

  • 20

  • ACR 300 mg/g

    Diabetic 140/90 mmHg(1B)

    130/80 mmHg(2D)

    130/80 mmHg(2D)

    Non

    diabetic

    140/90 mmHg(1B)

    130/80 mmHg(2D)

    130/80 mmHg(2D)

    Minimising CKD progression (and CV risk) BP control

    ACE-I or ARB 1st choice

    A1 A2 A3

  • Heeg et al, KI 1989

    The anti-proteinuric effect of lisinopril is dose and time related,

    and strongly dependent on dietary sodium restriction

    Low Salt intake= 50 High salt = 200 mmol/day

  • Salt restriction or diuretics :

    similar potentiation of ACE-I effect

    Buter et al, Nephrol Dial Transplant 1998

    Low sodium= 50 mmol/dHigh sodium = 200 mmol/d

    Addition of HCT -> 10% BP 40% proteinuria

  • Dual RAAS blockade in CKD ?

  • 28

  • Dual RAAS blockade ?

    Nephro-protection : reducing proteinuria with medium to long-term renoprotective effect (dialysis

    later ... or never)

    Nephro-risk: acute worsening of renal failure and hyperK if intercurrent disease (gastroenteritis ++,..)

    So block RAAS : YES but usually single agent (ACEior ARB) + possibly micro cardio dose of

    spironolactone

    Association ACE I + ARB : only if heavy proteinuria( glomerular), with close, careful nephrology follow-up in reliable patients

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  • No BP differences between groups

  • 44

    Conclusions

    Albuminuria = a strong , independentprognostic marker of high risk of poor outcomes Urinalysis still underused in the follow-up of diabetic patients Albuminuria /proteinuria can /should betreated

    - optimal BP control- RAS blockade (usually single agent)- low salt intake and /or diuretics- other drugs ? (pentoxyfilline?)