Chronic Kidney Disease Chronic Kidney Disease (CKD) and Diabetes(CKD) and Diabetes
June 20, 2007June 20, 2007
Alfred K. Cheung, M.D.Alfred K. Cheung, M.D.
University of UtahUniversity of Utah
Current Terminology
• Kidney, not Renal (or Reno)
• CKD, not CRF
• DKD (= diabetic nephropathy)
• AKI, not ARF
• Still ESRD (End Stage Renal Disease)
• Still RRT (Renal Replacement Therapy)
Importance of Diabetic Kidney Disease
• Kidney disease as diabetic complication:– 30% of Type 1 Diabetes– 40% of Type 2 Diabetes
• CKD amplifies CVD risk of diabetes
Diabetic Kidney Disease Screening
• WHEN– Type 1: after 5 years, then annually– Type 2: at diagnosis, then annually
• HOW– Albumin-to-Creatinine ratio in random urine
• Microalbuminuria = 30-300 mg/g• Macroproteinuria
– Estimate GFR (eGFR) from serum creatinine using formulas
– Retinopathy: useful clue
Stages of CKD
Stage ICD-9 GFR (mL/min/1.73M2)
1 585.1 > 91 + damage
2 585.2 60-89 + damage
3 585.3 30-59
4 585.4 15-29
5 585.5 < 15
6 585.6 ESRD on RRT
Action Plan in the Clinic
• Determine AKI vs. CKD?• Estimate GFR and rate of decline• Identify kidney disease requiring specific Rx• Slow progression of CKD• Review medications• Identify + treat systemic complications• Prepare for replacement therapy
Depending on CKD Stage
Formulas for Estimating GFR
• Cockcroft-Gault• MDRD (Modification of Diet in Renal Disease Study)
– GFR calculator (www.kidney.org)
• GFR depends on:– Serum creatinine– Age– Gender– Race
Interventions to Slow CKD Progression
• Strong evidence– Blood pressure control– ACEI / ARB– Glucose control in DM
• Weaker evidence– Protein restriction– Lowering LDL cholesterol
Management of Albuminuria in Normotensive Diabetic
• Normotensive DM patients with macroalbuminuria should be treated with ACEI / ARB
• Treatment with an ACE inhibitor or an ARB should be considered in normotensive persons with diabetes and microalbuminuria
AKI Superimposed on CKD
• Dehydration
• BP too low
• Obstruction
• Contract dye
• Drugs– Nephrotoxic or allergic or hemodynamic– NSAID (including Cox-2 inhibitors)– ACEI / ARB
Systemic Complications of CKD
• Hypertension
• Cardiovascular disease
• Anemia
• Calcium-phosphorus-parathyroid
American Heart Association
• Patients with CKD– Should be considered as highest-risk group
for CVD– Should be treated as such
Sarnak, Circ, 2004
Erythropoietin Stimulating Agent in CKD
• Administration (SQ q 1-4 wk)– Epoietin-α (start 75-150 units/kg)– Darbepoetin (start 0.45 μg/kg)
• Target Hgb (11-12 g/dL)
• Adverse effects– Iron deficiency (may need IV iron)– Hypertension
What is Renal Diet?
• Low sodium
• Low potassium– What about DASH?
• Low phosphorus– Adding glucose and fat targets?
• Should be individualized
Symptoms of Uremia
• None or subtle
• Fatigue, lack of energy
• Anorexia (nausea/vomiting)
• Sleep disturbance
• Impaired cognitive function
• Impotence
When to Start Replacement Therapy
• Phophorus higher than hct• Pale and sallow• Needs a razor blade to scratch the itch• Vomiting day & night• Legs twitching• Hands flapping• Uremic smell you cannot stand
• Too late!!• Should start no later than mildly symptomatic• Usually GFR 7-8 mL/min
Preparation for RRT
• GFR 20 mL/min (depends on rate of decline)
• Early CKD education (including diet)
• Early nephrology referral for co-management (delineate responsibilities)
• Arm vein preservation