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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. LucUniversité 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 <30
Hypertension G2 60-89
Glom Disease G3a 45-59
A2 30-299
Transplant G3b 30-44
Unknown G4 15-29
A3 ≥300
etc G5 <15
N to mildly increased
Dipstick neg to trace
Moderately increased
Dipstick trace to +
Severely increased
Dipstick > +
Staging of CKD (CGA staging)
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 <30mg/g 30-300 mg/g > 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 (ACEi
or ARB) + possibly micro « cardio » dose of
spironolactone
Association ACE I + ARB : only if heavy proteinuria
(“ glomerular”), with close, careful nephrology
follow-up in reliable patients32
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?)