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