Post on 30-Mar-2015
William Vega-Ocasio MD.William Vega-Ocasio MD.Internal Medicine - NephrologyInternal Medicine - Nephrology
Centro Renal Hospital Menonita CayeyCentro Renal Hospital Menonita Cayey787-535-1001 Ext. 5503787-535-1001 Ext. 5503
vowilliam@usa.netvowilliam@usa.net
Diabetic NephropathyThe Dietitian Intervention
ObjectivesObjectives
Definition of Diabetic Nephropathy
Prevention and management of Diabetic Nephropathy
Nutritional Management of Diabetics with Advance Renal Disease
OverviewOverview
Diabetes MellitusDiabetes Mellitus Disorder of impaired carbohydrates Disorder of impaired carbohydrates
metabolism.metabolism. Either Insulin deficiency or Insulin resistant Either Insulin deficiency or Insulin resistant
state.state. Characterized by hyperglycemia (inadequate Characterized by hyperglycemia (inadequate
production or utilization of insulin).production or utilization of insulin). Multi systemic organ damage : Multi systemic organ damage : eyes, nerves, eyes, nerves,
blood vessels, heart and kidneys.blood vessels, heart and kidneys.
OverviewOverview Diabetes MellitusDiabetes Mellitus
Advance glycosylation of tissue proteins (AGEP)Advance glycosylation of tissue proteins (AGEP)
Irreversible Irreversible glycosylation of Hemoglobinglycosylation of Hemoglobin
Microvascular damage ( nephropathy & Microvascular damage ( nephropathy &
retinopathy)retinopathy)
Renal and Cardiovascular complicationsRenal and Cardiovascular complications
Direct effect in Lipid metabolismDirect effect in Lipid metabolism
Diabetic NephropathyDiabetic Nephropathy
Leading cause of and contributor to End Stage Leading cause of and contributor to End Stage Renal Disease “ESRD” (CKD V)Renal Disease “ESRD” (CKD V)
Development is related to Development is related to durationduration of diabetes of diabetes and and degreedegree of hyperglycemia of hyperglycemia
Progresses in stages to CKD V if not treatedProgresses in stages to CKD V if not treated
Diabetic NephropathyDiabetic Nephropathy
Occurs in both DM Type I & IIOccurs in both DM Type I & II
Peak incidence of disease for Type I diabetics is Peak incidence of disease for Type I diabetics is between 10 - 15 years after onset of diseasebetween 10 - 15 years after onset of disease
Usually already present for those diagnosed with Usually already present for those diagnosed with Type II DiabetesType II Diabetes
Diabetic NephropathyDiabetic Nephropathy
CarbohydratesLoad
Increased Transforming Growth factor
Angiotensin Platelet Derived Growth factor
Abnormally Regulated Thromboxanes and Endothelins
Microvascular Damage
Insulin DeficiencyHyperglycemia
HEART
VASCULAR SYSTEM
KIDNEY
Diabetic NephropathyDiabetic Nephropathy
Characterized :Characterized : Microvacular damage to kidneyMicrovacular damage to kidney Earliest clinical evidence is appearance of Earliest clinical evidence is appearance of
microalbuminuria (microalbuminuria (incipient nephropathyincipient nephropathy)) Slowly progressive disorderSlowly progressive disorder Untreated will result in massive protein Untreated will result in massive protein
excretion and decreased glomerular filtration excretion and decreased glomerular filtration rate (rate (↓ GFR)↓ GFR)
Untreated Diabetic NephropathyUntreated Diabetic Nephropathy
Diabetic NephropathyDiabetic Nephropathy
HyperglycemiaHyperglycemia
NephropathyNephropathy
ESRDESRD
Diabetic NephropathyDiabetic Nephropathy
STAGESTAGE GFRGFR URINE PROTEINURINE PROTEIN BPBP
I. Hyperfiltration Super normal <30mg/day NormalI. Hyperfiltration Super normal <30mg/day Normal
II. Micro- Alb High-Normal 30-300mg/day RisingII. Micro- Alb High-Normal 30-300mg/day Rising
III. Proteinuria Normal-Decreasing <300mg/day ElevatedIII. Proteinuria Normal-Decreasing <300mg/day Elevated
IV. Nephropathy Decreasing Increasing ElevatedIV. Nephropathy Decreasing Increasing Elevated
V. ESRD <15mL/min Massive ElevatedV. ESRD <15mL/min Massive Elevated
National Kidney Foundation “Primer on Kidney Diseases” Fourth edition Elsevier Saunders
From EdREN, the website of the Renal Unit of the Royal Infirmary of Edinburgh
Diabetic Nephropathy Stage I Diabetic Nephropathy Stage I
Stage I-AStage I-A Increased Kidney Increased Kidney
Filtration Filtration Osmotic load and Osmotic load and
Toxic effects of Toxic effects of hyperglycemiahyperglycemia
Increased Glomerular Increased Glomerular Filtration RateFiltration Rate
Kidney enlargementKidney enlargement
Stage I-BStage I-B Silent PhaseSilent Phase HyperfiltrationHyperfiltration HypertrophyHypertrophy Increased production Increased production
of inflammatory of inflammatory mediatorsmediators
Diabetic Nephropathy Stage IIDiabetic Nephropathy Stage II
Microalbuminuria (30-300mg/day)Microalbuminuria (30-300mg/day) Basement membrane thickening due to Basement membrane thickening due to
AGEP’sAGEP’s Increased Microvascular damageIncreased Microvascular damage Cardiovascular disease and Cardiovascular disease and retinopathyretinopathy 20% risk of 20% risk of nephropathynephropathy within 5 years with within 5 years with
standard carestandard care Glomerular Filtration RateGlomerular Filtration Rate not markedly not markedly
affected, but kidney inflammatory damageaffected, but kidney inflammatory damage
Diabetic Nephropathy Stage IIIDiabetic Nephropathy Stage III
Proteinuria (>300mg/day)Proteinuria (>300mg/day) Decreased Glomerular filtration RateDecreased Glomerular filtration Rate Severe proteinSevere protein wastingwasting with it complications with it complications Up to 10% of patients may excrete Up to 10% of patients may excrete
< 3000mg/day< 3000mg/day Systemic microvascular and cardiovascular Systemic microvascular and cardiovascular
disease complicationsdisease complications Abnormal lipid metabolism (Cholesterol & Abnormal lipid metabolism (Cholesterol &
Triglycerides)Triglycerides)
Diabetic Nephropathy Stage IVDiabetic Nephropathy Stage IV
Prepare for TreatmentPrepare for Treatment
Progressive nephropathyProgressive nephropathy Markedly decreased GFRMarkedly decreased GFR Signs and Symptoms of Protein Calorie Signs and Symptoms of Protein Calorie
malnutritionmalnutrition Advance RetinopathyAdvance Retinopathy Cardiovascular catastrophes Cardiovascular catastrophes Cerebrovascular catastrophesCerebrovascular catastrophes
Diabetic Nephropathy Stage VDiabetic Nephropathy Stage V
End Stage Renal Disease (CKD V)End Stage Renal Disease (CKD V)
Renal Replacement therapyRenal Replacement therapy Severe protein calorie malnutritionSevere protein calorie malnutrition Severe peripherovasclular diseaseSevere peripherovasclular disease Cerebrovascular DiseaseCerebrovascular Disease Cardiovascular DiseaseCardiovascular Disease InfectionsInfections
ObjectivesObjectives
Definition of Diabetic Nephropathy
Prevention and management of Diabetic Nephropathy
Nutritional Management of Diabetics with advance Renal Disease
Diabetic NephropathyDiabetic Nephropathy
HyperglycemiaHyperglycemia
NephropathyNephropathy
ESRDESRD
Progression of Disease
Regression of Disease
National Kidney Foundation
Diabetic NephropathyDiabetic Nephropathy
Stages of CKDStages of CKD I : Above normal GFRI : Above normal GFR II : Glomerular Damage, Microalbuminuria II : Glomerular Damage, Microalbuminuria
(30-300mg/day) (30-300mg/day) III : Proteinuria (>300mg/day),HypertensionIII : Proteinuria (>300mg/day),Hypertension IV : More Glomerular Damage, Increasing IV : More Glomerular Damage, Increasing
Proteinuria, Decreased GFR Proteinuria, Decreased GFR → Azotemia→ Azotemia V : GFR < 15ml/min/1.73mV : GFR < 15ml/min/1.73m2 2 → Renal → Renal
Replacement Therapy Replacement Therapy
From Chronic Kidney Disease, Dialysis, and Transplantation, Second Edition, Elsevier Saunders 2005
From Chronic Kidney Disease, Dialysis, and Transplantation, Second Edition, Elsevier Saunders 2005
Prevention or Regression Prevention or Regression of Diseaseof Disease
Prevention or Regression Prevention or Regression of Diseaseof Disease
Glycemic ControlGlycemic Control Hypertension ControlHypertension Control Control Microalbuminuria or Control Microalbuminuria or
ProteinuriaProteinuria Dietary Protein Restriction*Dietary Protein Restriction* Treatment of DyslipidemiasTreatment of Dyslipidemias
Glycemic ControlGlycemic Control Partially reverse glomerular hypertrophy and Partially reverse glomerular hypertrophy and
hyperfiltrationhyperfiltration Delay development of microalbuminuriaDelay development of microalbuminuria Delay the onset or progression of Delay the onset or progression of
nephropathynephropathy Delay onset of microvascular damage to Delay onset of microvascular damage to
organsorgans
Diabetic NephropathyDiabetic Nephropathy
Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes
Diabetic NephropathyDiabetic Nephropathy
Hypertension ControlHypertension Control Single Single most effectivemost effective measure for delaying measure for delaying
progression of Chronic Kidney Disease progression of Chronic Kidney Disease Aggressive treatment is able to decrease the Aggressive treatment is able to decrease the
rate of Diabetic Nephropathy Progressionrate of Diabetic Nephropathy Progression Reduce microvascular cardiac, retinal and Reduce microvascular cardiac, retinal and
systemic complicationssystemic complications Goal BP Target Goal BP Target ≤ 130/85 in diabetics≤ 130/85 in diabetics Goal BP Target Goal BP Target ≤ 125/75 in nephropathy≤ 125/75 in nephropathy
Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes
Diabetic NephropathyDiabetic Nephropathy
Antihypertensive AgentsAntihypertensive Agents
Angiotensin converting enzyme inhibitors (ACE)Angiotensin converting enzyme inhibitors (ACE) Angiotensin Receptor Blocker (ARB)Angiotensin Receptor Blocker (ARB) Calcium Channel Blocker (CCB)Calcium Channel Blocker (CCB) Diuretics ( Loop and Thiazides )Diuretics ( Loop and Thiazides ) ββ – Blockers – Blockers αα – Blockers – Blockers
Diabetic NephropathyDiabetic Nephropathy
Control Microalbuminuria or ProteinuriaControl Microalbuminuria or Proteinuria Untreated will accelerate the progression of Untreated will accelerate the progression of
diabetic nephropathydiabetic nephropathy ACE inhibitorsACE inhibitors delay progression of delay progression of
nephropathy in Type I DMnephropathy in Type I DM ACE inhibitors and ARB’sACE inhibitors and ARB’s delay progression delay progression
from microalbuminuria to proteinuria In Type II from microalbuminuria to proteinuria In Type II DMDM
ARB’sARB’s delay progression to nephropathy in delay progression to nephropathy in Type II DM with HTN and CKDType II DM with HTN and CKD
Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes
Diabetic NephropathyDiabetic Nephropathy
Dietary Protein RestrictionDietary Protein Restriction
CarefulCareful Restriction Restriction Not all patients are candidatesNot all patients are candidates Helps by reducing hyperfiltrationHelps by reducing hyperfiltration Helps by reducing intraglomerular pressureHelps by reducing intraglomerular pressure Retards progression of renal diseaseRetards progression of renal disease Recommendations 0.6 - 0.8 grams per Recommendations 0.6 - 0.8 grams per
kilogram of body weight a daykilogram of body weight a day
Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes
STOP !!!STOP !!!
Diabetic NephropathyDiabetic Nephropathy
Proteinuria :Proteinuria : Loss of ImmunoglobulinsLoss of Immunoglobulins Loss of lipoproteinsLoss of lipoproteins Loss of tissue regeneration proteinsLoss of tissue regeneration proteins Protein Calorie MalnutritionProtein Calorie Malnutrition
Protein Restriction ?Protein Restriction ?
Diabetic NephropathyDiabetic Nephropathy
……low protein diets may actually harm this low protein diets may actually harm this population, primarily by aggravating population, primarily by aggravating malnutrition….malnutrition….
Diabetic NephropathyDiabetic Nephropathy
……there is suggestive clinical and there is suggestive clinical and experimental evidence that dietary protein experimental evidence that dietary protein restriction may be restriction may be ineffectiveineffective in CKD in CKD patients patients receiving standard anti-proteinuricreceiving standard anti-proteinuric therapy with therapy with ACE inhibitors or ARB’sACE inhibitors or ARB’s..
Diabetic NephropathyDiabetic Nephropathy
……low protein diets are associated with low protein diets are associated with both statistically and clinically significant both statistically and clinically significant declines in nutritional markersdeclines in nutritional markers in CKD in CKD populations, in whom the prevalence of populations, in whom the prevalence of malnutrition is 50%.malnutrition is 50%.
Diabetic NephropathyDiabetic Nephropathy
Treatment of DyslipidemiasTreatment of Dyslipidemias Important in prevention of atherosclerosisImportant in prevention of atherosclerosis Reductase inhibitors (Statins) may protect Reductase inhibitors (Statins) may protect
against glomerulosclerosisagainst glomerulosclerosis ADA Goals for Lipids:ADA Goals for Lipids:
• LDL LDL ≤ 100 mg/dL≤ 100 mg/dL• HDL ≥ 40 mg/dLHDL ≥ 40 mg/dL
ObjectivesObjectives
Definition of Diabetic Nephropathy
Prevention and management of Diabetic Nephropathy
Nutritional Management of Diabetics with advance Renal Disease
Levey, A. S. et. al. Ann Intern Med 2003;139:137-147
Evidence model for stages in the initiation and progression of chronic kidney disease (CKD) and therapeutic
interventions
Diabetic NephropathyDiabetic Nephropathy
Management Early stages ( I & II) :Management Early stages ( I & II) : Strict Glycemic control !!!Strict Glycemic control !!! Potassium Restriction Potassium Restriction Treatment of dyslipidemiasTreatment of dyslipidemias Sodium RestrictionSodium Restriction Remove Irritants from dietRemove Irritants from diet Nutritional Supplements ( FA, Iron, etc..)Nutritional Supplements ( FA, Iron, etc..) Family support PlanFamily support Plan
Diabetic NephropathyDiabetic Nephropathy
Management Advanced stages ( III & IV) :Management Advanced stages ( III & IV) : Glycemic control, Glycemic control, avoid hypoglycemiaavoid hypoglycemia !!! !!! Potassium RestrictionPotassium Restriction !!! !!! Phosphorus RestrictionPhosphorus Restriction Treatment of dyslipidemiasTreatment of dyslipidemias Sodium Sodium RemovalRemoval from diet from diet Remove Irritants from dietRemove Irritants from diet Nutritional Supplements ( FA, Iron, etc..)Nutritional Supplements ( FA, Iron, etc..) Prepare for TreatmentPrepare for Treatment
SummarySummary
Early referral is essential !!!Early referral is essential !!! Work with your nephrologists or Work with your nephrologists or
endocrinologistendocrinologist Identify, treat and prevent malnutritionIdentify, treat and prevent malnutrition Know your patients medicationsKnow your patients medications Join educational effortsJoin educational efforts
Thank You !!!Thank You !!!