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MANAGEMENT OF DM IN CKD DIFFFERS AS THE OHA SHOULD BE USED CAUTIOUSLY AND ALSO INSULIN..
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by
Dr.Sridhar DM (nephrology)
MANAGEMENT OF DIABETES MELLITUS
IN CKD
DIABETES:THE MOST COMMON CAUSE OF ESRD
Primary Diagnosis for Patients Who Start Dialysis
Diabetes50.1%
Hypertension27%
Glomerulonephritis
13%
Other
10% No. of patientsProjection95% CI
1984 1988 1992 1996 2000 2004 20080
100
200
300
400
500
600
700
r2=99.8%243,524
281,355520,240
No.
of d
ialy
sis
patie
nts
(thou
sand
s)
COMORBIDITIES
Non-diabetes Diabetes
Non-CKD
CKD
0
15
30
45
60
Non-diabetes Diabetes
Non-CKD
CKD
0
15
30
45
60
Non-diabetes Diabetes
Non-CKD
CKD
0
15
30
45
60
Non-diabetes Diabetes
Non-CKD
CKD
0
15
30
45
60
%Stroke/TIA
%ASHD %Amputation/PVD
%Heart Failure
CAUSES OF RENAL DISEASE IN DIABETES
• Diabetic nephropathy• Renal artery stenosis• Myeloma, outflow obstruction, polycystic renal disease,
glomerulonephritis, etc• Drugs
• NSAIDS/Cox 2 inhibitors• Fibrates• ACEI, ARBs
DIABETIC NEPHROPATHY
• 30% of all end-stage renal disease
• Increased co-morbidity and mortality – retinopathy, cardiovascular disease, stroke, peripheral vascular disease
• May be prevented/delayed by early screening and treatment
FACTORS AFFECTING PROGRESSION OF NEPHROPATHY
• Blood pressure
• Urinary protein excretion
• (glycaemic control)
MINIMUM SCREENING FOR RENAL DISEASE IN DIABETES
1. Annual EMU for ACR. Repeat within a month if positive, in absence of UTI/renal stones/other renal disease
2. Annual serum creatinine• Creatinine• eGFR (preferred MDRD equation)
MICROALBUMINURIA AND PROTEINURIA
Normal Microalbuminuria Overt proteinuria
F M F M
Albumin/creatinine ratio (mg/mmol)
<3.5 <2.5 >3.5 >2.5 >30
Equivalent Albumen excretion (mg/day)
<30 30-300 300
• Diagnosis of microalbuminuria based on 2 out of 3 positive first passed morning urine samples in absence of urinary tract infection
INITIAL ASSESSMENT OF PATIENT WITH DIABETES AND RENAL IMPAIRMENT
• Is this likely to be diabetic nephropathy?
• Presence of retinopathy
• Microalbuminuria/proteinuria
• Is this likely to be renal artery stenosis?
• Family history, Drug history, GU history etc
• AIP, myeloma screen, PSA
• Ultrasound
METFORMIN
• Metformin has been used in low doses in patients with glomerular filtration rate (GFR) as low as 30 to 60 ml/min. It
• should not be used at a GFR below 30 ml/min -- risk for lactic acidosis.
• As renal function can deteriorate abruptly,
• better to avoid metformin once serum creatinine concentration rises above
1.5 mg/dl (132 μmo/l) in men
1.3 mg/dl (117 μmol/l) in women
ORAL HYPOGLYCEMICS
INSULIN SECRETAGOGUES(SULFONYLUREA AND MEGLITINIDES)
• Sulphonylureas (especially gliblenclamide) may accumulate as renal function deteriorates
• can be associated with hypoglycemia
Glycosidase inhibitors• contraindicated in renal failure
Thiazolidinediones• associated with weight gain, (fluid retention + nonfluid gains)
• patients at risk for congestive heart failure -- should be avoided.
• Concern about increased bone fracture rates in patients using thiazolidinediones,
• could potentiate CKD - related bone disease.
• Insulin regimens are the most commonly used to control glycemia in CKD
• increasing half-life of insulin as CKD progresses, the risk for hypoglycemia increases.
• Insulin requirements decrease further in HD patients, particularly in those with residual diuresis (<500 ml/day),
• Insulin requirement often decreases by 30%
• In peritoneal dialysis (PD) patients,
• intraperitoneal insulin is more physiologic than subcutaneous, as portal absorption of insulin may better mimic the endogenous insulin effect.
• Insulin requirements typically increase by 200% to 300% in this situation
INSULIN
INSULIN IN PT. ON HEMODIALYSIS
• Insulin inhibitors – dialyzable
• Insulin resistance diminishes after the start of dialysis.
• half-life of insulin is prolonged.
• the potential for hypoglycemia with both oral agents and insulin increases in the presence of CKD (with the exception of gliquidone and glimepiride).
• Self-monitoring of blood glucose concentration is imperative.
• Insulin requirement often decreases by ~30%
• Glargine has been shown to reduce hypoglycemia in hemodialysis patients
BLOOD PRESSURE CONTROL
• BP reduction in type 1 & type 2 DM patients reduces rate of CKD progression
• At any given level of GFR, blood pressure tends to be higher in diabetic than in nondiabetic patients with CKD
• recommended blood pressure target 125/75 mm Hg
• Ideally – (typically takes three or four drugs to accomplish)
• start with an ACE inhibitor or ARB
• Add diuretic
• Add calcium channel blocker, β-blocker, or renin inhibitors
(if systolic BP >20 mmHg above goal)START with ACEI or ARB/thiazide diuretic*)
If BP Still Not at Goal (125/705mm Hg)
If BP Still Not at Goal (125/75 mm Hg)
orIf used CCB, Add Other Subgroup of CCB
(ie, amlodipine-like agent if verapamil or diltiazem already being used and the converse)
OR if b blocker used add CCB
Add Vasodilator (hydralazine, minoxidil)
If BP Still Not at Goal (125/75 mm Hg)
Add Long Acting Thiazide Diuretic*
If Blood Pressure >125/75 mm Hg in Diabetes or Chronic Kidney Disease with Any Level of Albuminuria
Recheck within 2-3 weeks
Recheck within 2-3 weeks
Recheck within 4 weeks
(if systolic BP< 20 mmHg above goal)Start ARB or ACE Inhibitor titrate upwards
Add CCB or b blocker** (titrate dose upward)
Consider low dose aldosterone antagonists#
ACEI/ARB begin at a low dose; increase dose at 4-week intervals to reduce microalbuminuriaantiproteinuric effects not necessarily attained at antihypertensive doses increase dose until proteinuria reduced by 30 to 50%
Titrate to maximal suppression of urinary albumin excretion for DM patients with persistent microalbuminuria despite intensive insulin therapy even without HTN
titration limited by adverse effects:• an acute increase in serum creatinine of 50% or more;
• renal artery stenosis;
• hypovolemia; congestive heart failure
• hyperkalemia resistant to corrective maneuvers
• ARB : consider for subjects with documented aldosterone escape
IMPACT OF DIABETES ON DIALYSIS BLOOD PRESSURE MANAGEMENT
• Autonomic Insufficiency
• BP drops and very labile
• Medial Calcificaton
• Wide pulse pressure
• Hypertensive Cardiomyopathy
• Preload
• Cardiac function
• After load
LIPID CONTROL
• Heart Protection Study
• Patients with DM and CKD who received statins had a 23% decrease in cardiovascular risk with an absolute event reduction of 80%
• In HD patients with type 2 DM, the addition of 20 mg of atorvastatin
• 40% decrease in lowdensity lipoprotein cholesterol levels & significant decrease in cardiac events
DOSAGES OF STATINS IN CKD• IN PT.S ON HEMODIALYSIS AND PERITONEAL DIALYSIS
• Atorvastatin - up to 80 mg/day
• Fluvastatin – up to 80 mg/day.
• Pravastatin - limited to 10 mg, as active metabolites can accumulate,
Pravastatin Pooling Project - of up to 40 mg were safely (GFR of 30 ml/min per 1.73 m2)
• Simvastatin – upto 20 mg/day (40-mg/day in stage 3 CKD (Heart Protection Study))
• Rosuvastatin - not more than 10 mg/day when GFR falls below 30 ml/min per 1.73 m2.
• Ezetimibe - safely used (effects absorption mainly bile acid sequestrants)
• Fenofibrate - reduced by one third in CKD stage 2,
reduced by two thirds in CKD stages 3 and 4
avoided in CKD stage 5.
• Gemfibrozil - safely used, although in PD, elevated CPK levels have been reported
• Niacin (Sustained-release) - should be decreased by 50% at CKD stage 5
• DIET IN CKD PT.S WITH DM• Diabetic patients with renal failure are often severely catabolic
and tend to develop malnutrition
• Reduction of dietary protein intake to 0.8 g/kg body weight for CKD Stages 1–4 is recommended
• Increase protien intake >1.2g/kg in HD >2.0g/kg in PD
• ANEMIA
• Anemia occurs at an earlier stage of CKD in DM patients and is often more severe
• Erythropoietin - Anemia associated with CKD
• In DM - higher dosages compared with nonDM pt.s
• Diabetic patients with CKD develop secondary hyperparathyroidism at a slower rate than nondiabetics
• predisposed to low-turnover (adynamic) bone disease - risk factor for cardiovascular calcification
• care should be taken to avoid calcium loading.
• Accumulate aluminum more readily and are more susceptible to aluminum-induced bone disease.
• Aluminum containing phosphate binders should always be avoided in the diabetic patient with advanced CKD
• Target serum phosphorus goal
• < 5.5 mg/dl in patients with Stage 5 CKD
• < 4.6 mg/dl in Stage 3–4 CKD.
• if the i-PTH is abnormal - evaluate for vitamin D deficiency
• measurement of 25-hydroxy vitamin D.
DIABETIC MANAGEMENT IN CKD
Parameter
• Lower BP………………………
• Block RAAS……………………
• Improve glycemia …………….
• Lower LDL cholesterol………..
• Anemia management ………...
• Endothelial protection…………
• Smoking………………………..
Target
< 125/75 mmHg
ACEi or ARB to max tolerated
A1c < 6.5% (Insulin/TZD)
< 100 (70) mg/dl statin + other
Hb 11-12 g/dl (Epo + iron)
Aspirin daily
Cessation
RENAL REPLACEMENT THERAPY IN CKD WITH DM• Start dialysis at eGFR - 15 ml/min per 1.73 m2 (normally - eGFR <7-8)
• they tend to tolerate uremia poorly and frequently have sodium retention and fluid overload.
• Peritoneal dialysis–associated glucose loading • Replace glucose solutions in part by amino acid solutions and polyglucose.
• Loss of solute and water transport often limits long-term use of peritoneal dialysis to 3 to 5 years.
• Switching to hemodialysis should be considered before volume overload or uremic symptoms occur
• Pt.s on PD, Glucose meters based on GLUCOSE OXIDASE TEST should be used • maltose and polyglucose present in PD solution, affect glucose
dehydrogenase–based glucose meters
TRANSPLANTS
• Type 1 DM - pancreas transplant
• Can induce regression of moderate Diabetic Nephropathy lesions in native kidneys
• but only during a period of 10 years after transplantation.
• Pancreas transplantation at the time of renal transplantation
• Prevents / slows the development of Diabetic Nephropathy in the transplanted kidney.
Thank you