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DIABETES AND THE DIABETES AND THE KIDNEYSKIDNEYS
Benita S. Padilla, M.D.Benita S. Padilla, M.D.
How does diabetes affect the kidneys?How does diabetes affect the kidneys?
About 20% of diabetics will develop diabetic About 20% of diabetics will develop diabetic
nephropathynephropathy
The glomeruli become deposited with abnormal The glomeruli become deposited with abnormal proteins, leading to inflammation and scarring proteins, leading to inflammation and scarring
Diabetic nephropathy is now the leading cause of Diabetic nephropathy is now the leading cause of ESRD in our countryESRD in our country
Diabetic nephropathy leads to progressive Diabetic nephropathy leads to progressive deterioration in kidney function deterioration in kidney function
Can we do anything to help our patients Can we do anything to help our patients avoid developing diabetic nephropathy? avoid developing diabetic nephropathy?
YES!!YES!!
Optimal blood sugar controlOptimal blood sugar control Optimal blood pressure controlOptimal blood pressure control
Can we do anything to help our patients Can we do anything to help our patients who already have diabetic nephropathy? who already have diabetic nephropathy?
YES!!YES!!
First, we must diagnose diabetic nephropathy at the earliest First, we must diagnose diabetic nephropathy at the earliest possible time -before the patient develops symptomspossible time -before the patient develops symptoms
How do we make an early diagnosis of How do we make an early diagnosis of diabetic nephropathy? diabetic nephropathy?
All diabetic patients should be screened All diabetic patients should be screened for MICROALBUMINURIAfor MICROALBUMINURIA
MICRO – small amount ofMICRO – small amount of
ALBUMINALBUMIN
URIA – in the urineURIA – in the urine
Defined as urine albumin between 30 and Defined as urine albumin between 30 and 300 mg/day300 mg/day
When should a diabetic be screened for MA? When should a diabetic be screened for MA?
For patients with type 1 DMFor patients with type 1 DM 5 years after initial diagnosis of DM, then annually thereafter 5 years after initial diagnosis of DM, then annually thereafter
For patients with type 2 DMFor patients with type 2 DM upon initial diagnosis of DM, then annually thereafterupon initial diagnosis of DM, then annually thereafter
How should screening for MA be done? How should screening for MA be done?
MA MA cannotcannot be detected by the ordinary be detected by the ordinary urinalysisurinalysis
A positive test for protein in the routine urinalysis A positive test for protein in the routine urinalysis means that the patient has means that the patient has macromacroalbuminuria already albuminuria already
MacroMacroalbuminuria is defined as albumin albuminuria is defined as albumin excretion excretion more than 300 mg/daymore than 300 mg/day
To review: To review:
MicroMicroalbuminuriaalbuminuria 30 to 300 30 to 300 mg/daymg/day
MacroMacroalbuminuria albuminuria >300 mg/day >300 mg/day
How should screening for MA be done? How should screening for MA be done?
Routine urinalysisRoutine urinalysis
(+) Protein?(+) Protein?
Micral test Micral test positive?positive?
Patient has Patient has MICROalbuminuriaMICROalbuminuria
Repeat after 1 yrRepeat after 1 yr Repeat within 3 mos Repeat within 3 mos to confirmto confirm
YESYES
YESYES
NONO
NONO
Patient has Patient has MACROalbuminuriaMACROalbuminuria
How can the onset and progression of diabetic How can the onset and progression of diabetic nephropathy be prevented? nephropathy be prevented?
Be meticulous about blood sugar controlBe meticulous about blood sugar control
Be meticulous about blood pressure Be meticulous about blood pressure controlcontrol
Goal: BP < 130/80 mm HgGoal: BP < 130/80 mm Hg
Goals:Goals: FPG < 120 mg/dl (6.7 mmol/L), FPG < 120 mg/dl (6.7 mmol/L), HbA1c < 7%)HbA1c < 7%)
Every 10 mm reduction in SBP reduces by 12% the Every 10 mm reduction in SBP reduces by 12% the risk of any complication due to DM!risk of any complication due to DM!
How can the onset and progression of diabetic How can the onset and progression of diabetic nephropathy be prevented? nephropathy be prevented?
Be careful with your choice of antihypertensive medicationsBe careful with your choice of antihypertensive medications
ACE inhibitors and ARBs are the drugs of choice in patients with DNACE inhibitors and ARBs are the drugs of choice in patients with DN
Screen for microalbuminuriaScreen for microalbuminuria
ACE inhibitors and ARBs are ACE inhibitors and ARBs are recommendedrecommended even if the patient is not even if the patient is not hypertensivehypertensive
How can the onset and progression of diabetic How can the onset and progression of diabetic nephropathy be prevented? nephropathy be prevented?
Discourage smoking stronglyDiscourage smoking strongly
Educate the patientEducate the patient
What are the late signs of diabetic What are the late signs of diabetic nephropathy? nephropathy?
MacroalbuminuriaMacroalbuminuria
Difficult to control hypertensionDifficult to control hypertension
Edema, ascitesEdema, ascites
Elevated BUN and creatinine Elevated BUN and creatinine
What are the late signs of diabetic What are the late signs of diabetic nephropathy? nephropathy?
Less need for anti-diabetic medicationsLess need for anti-diabetic medications
Nausea and vomitingNausea and vomiting
Weakness and pallorWeakness and pallor
When should you refer a patient with diabetic When should you refer a patient with diabetic nephropathy to a nephrologist? nephropathy to a nephrologist?
When albuminuria is first detected even if When albuminuria is first detected even if BUN and creatinine are normal!!BUN and creatinine are normal!!
Very important to intervene early to Very important to intervene early to prevent progression to renal failureprevent progression to renal failure
Take home messsages Take home messsages
Screening for microalbuminuria is the Screening for microalbuminuria is the most effective way of detecting early most effective way of detecting early diabetic nephropathydiabetic nephropathy
Early diagnosis is extremely important because it is Early diagnosis is extremely important because it is possible to retard progression of renal diseasepossible to retard progression of renal disease
Take home messsages Take home messsages
ACE inhibitors or angiotensin receptor ACE inhibitors or angiotensin receptor blockers must be given in all patients with blockers must be given in all patients with diabetic nephropathy!! diabetic nephropathy!!
You must think of the nephrologist not as someone you refer You must think of the nephrologist not as someone you refer to because your patient has kidney failure but someone you to because your patient has kidney failure but someone you refer to so that your patient will not develop kidney failurerefer to so that your patient will not develop kidney failure
Barangay, Municipal and District LevelBarangay, Municipal and District Level
Screen all patients for diabetesScreen all patients for diabetes All adults should have an FPG or casual plasma glucose every 2 years 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 twiceDM 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 Refer all newly diagnosed diabetics for initial work-upwork-up
Reinforce compliance with therapeutic lifestyle changesReinforce compliance with therapeutic lifestyle changes
Barangay, Municipal and District LevelBarangay, Municipal and District Level
Monitor and encourage compliance with prescribed diabetic medicationsMonitor and encourage compliance with prescribed diabetic medications
Monitor patient to check whether therapeutic goals are being achievedMonitor patient to check whether therapeutic goals are being achieved
Refer patient if therapeutic goals are not achieved or patient develops new Refer patient if therapeutic goals are not achieved or patient develops new symptoms symptoms
Provincial LevelProvincial Level
Perform initial laboratory work-up recommended for Perform initial laboratory work-up recommended for all newly diagnosed diabeticsall newly diagnosed diabetics
Refer patients identified to have Refer patients identified to have target organ damagetarget organ damage to the appropriate specialist to the appropriate specialist
Regional and Specialty Hospital LevelRegional and Specialty Hospital Level
Assess for presence of and severity of target organ Assess for presence of and severity of target organ damagedamage
For those with renal abnormalities, a nephrologist should For those with renal abnormalities, a nephrologist should formulate a management plan to improve renal status and/or formulate a management plan to improve renal status and/or prevent further kidney damage prevent further kidney damage