Analysis and Treatment of Diabetic Nephropathy SFM Didactics January 14, 2003 Carol Cordy, MD .


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1. Why would it be a good idea for you to screen for diabetic nephropathy? 2. By what method would it be advisable for you to screen for diabetic nephropathy? 3. What would it be a good idea for you to do with the consequences of your screening tests?. . Why screen? Why treat?. Aversion and treatment of diabetic nephropathy can lessen the frequency of end stage renal ailment and passing.
Transcripts
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Finding and Treatment of Diabetic Nephropathy SFM Didactics January 14, 2003 Carol Cordy, MD

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1. Why would it be a good idea for you to screen for diabetic nephropathy? 2. In what capacity would it be a good idea for you to screen for diabetic nephropathy? 3. What would it be advisable for you to do with the aftereffects of your screening tests?

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Why screen? Why treat? Counteractive action and treatment of diabetic nephropathy can diminish the rate of end stage renal sickness and demise

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Diabetic Nephropathy and ESRD Diabetic nephropathy is the main source of end stage renal illness in the United States representing more than 40% of dialysis patients The 5-year death rate for a dialysis patient is 93% Dialysis for one patient expenses over $50,000 every year

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Epidemiology Type 1 Diabetic 25 - 45% will create diabetic nephropathy 80 - 90% with microalbuminuria will advance to unmistakable diabetic nephropathy in 5 - 10 years about 100% with gross proteinuria will advance to ESRD in 7 - 10 yrs

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Epidemiology Type 2 Diabetic half will have microalbuminuria at the time of presentation presumably optional to HTN 10-20% with microalbuminuria will progress to plain nephropathy minority populaces have a 2 to 20-crease higher rate of diabetic nephropathy

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Risk Factors for Diabetic Nephropathy Age, Race, Ethnicity History of microalbuminuria Hypertension Poor glycemic control Smoking Family history of nephropathy hereditary anomalies of ACE quality

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Stages of Diabetic Nephropathy Stage I – Hyperfiltration - expanded blood move through the kidney, early renal hypertrophy Stage II - Glomerular injuries without clinically apparent malady Stage III - Incipient nephropathy with microalbuminuria - alb/cr proportion .03 - .3 or egg whites 20-200 mcg/min on coordinated example

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Stages of Diabetic Nephropathy II III I IV V

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Stages of Diabetic Nephropathy Stage IV - Overt diabetic nephropathy with proteinuria >500 mg/24 hr - creatinine freedom <70 ml/min Stage V – End arrange renal ailment (ESRD) - creatinine leeway <15 ml/min - creatinine = 6mg/dl

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Stages of Diabetic Nephropathy II III I IV V

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Primary care doctors have the most continuous contact with diabetic patients and in this manner have the best potential to positively influence their wellbeing

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How are we doing? Thinks about demonstrate that essential care doctors screen just 20% of their diabetic patients for diabetic nephropathy

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How are we doing? Once screened numerous doctors are not certain what to do with the outcomes

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Diabetic Nephropathy Algorithm Evidence-based approach Goal – The utilization of the calculation will enhance renal capacity screening in the diabetic populace and energize the start of fitting treatment in patients with all phases of renal malady

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Using the Algorithm

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UA (Urine Dipstick) Use as an underlying screen for all patients Negative to follow proteinuria requires additionally testing for microalbuminuria 1+ or more noteworthy proteinuria requires additionally testing to quantitate proteinuria Once a patient has microalbuminuria, UA (pee dipstick) testing for gross proteinuria might be satisfactory albeit yearly testing for albuminuria may have turned out to be standard of care

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Microalbuminuria Spot AM pee: Alb/Cr proportion .03-.3* Timed pee gathering: 20-200µg egg whites/min 24 hour pee accumulation : 30-300 mg egg whites in 24 hours *This is the most useful test

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Microalbumin Testing Factors that Cause False Positive Test inadequately controlled diabetes bleak corpulence intense sickness, fever, UTI pregnancy, feminine cycle high protein consume less calories CHF hematuria, real anxiety: surgery or anesthesia

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Incipient Nephropathy Type 1 Diabetes 2 out of 3 pee tests + for microalbuminuria (begin screening 5 years after the underlying analysis) nearness of proliferative diabetic retinopathy 80-90% of sort 1 patients with microalbuminuria will advance to DN

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Incipient Nephropathy Type 2 Diabetes 2 out of 3 pee tests + for microalbuminuria (begin screening at the season of conclusion of diabetes) nearness of diabetic retinopathy 20-30% may have diabetic nephropathy yet not diabetic retinopathy 25% may have a finding of nephropathy other than diabetic nephropathy

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Macroalbuminuria Spot AM pee: Alb/Cr proportion more noteworthy than .3 Timed pee gathering: more noteworthy than 200µg egg whites/min 24 hour pee gathering : more noteworthy than 300 mg egg whites in 24 hours If macroalbuminuria is available then test for gross proteinuria

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Gross Proteinuria Defined as pee protein >500mg/24 hr. Best quality level test is 24 hour pee accumulation for aggregate protein and creatinine leeway Can likewise test protein/creatinine proportion measures add up to mg protein/mg creatinine correlates 1:1 with a 24 hr pee in grams/24 hr less precise in ARF, intersitial nephritis, high degrees of proteinuria

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Overt Diabetic Nephropathy Gold Standard is biopsy Diagnosis can be made by clinical history and prohibition of other renal sickness Workup incorporates Renal ultrasound for size, shape, irregularities 24 hour pee for aggregate protein and creatinine freedom

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Treatment Lifestyle changes Lose weight Stop smoking Low salt eating regimen for BP control Low protein eat less carbs? Glycemic Control Benefit in both Type 1 and Type 2 patients Recommended: HbA1C <7.0% (some say <6.5%)

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Blood Pressure Control Current ADA suggestions are for circulatory strain <130/80-85 (if nephropathy <125/75) Several randomized controlled trials demonstrate that enhanced pulse control diminishes the rate of movement of renal sickness in both sort 1 and sort 2 patients

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ACE\'s and ARB\'s Angiotensin changing over catalyst inhibitors and angiotensin receptor blocking specialists have been appeared in creature models and in randomized controlled trials to enhance diabetic nephropathy Mechanism of activity - ACE-inhibitors restrict angiotensin II generation by blocking angiotensin changing over chemical, ARB-operators piece angiotensin II receptors

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Questions for future reviews Will higher measurements of ACE\'s and ARB\'s enhance result and lessening microalbuminuria? Will patients without microalbuminuria advantage from the utilization of ACE\'s and ARB\'s? Shouldn\'t something be said about other BP prescriptions for patients who can\'t endure ACE\'s and ARB\'s? Which of the more up to date oral specialists for glucose control are likewise renal defensive? Is there a place for low protein diets for diabetics before renal sickness creates?

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Case #1 Your first patient is a 25 year old young fellow with a 5 year history of sort 1 diabetes. His pee dipstick is negative for protein. You check a spot AM pee alb/cr proportion which is .019. His pulse is 112/66. His HbA1C is 6.9.

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Which is (are) valid? The patient has early or nascent diabetic nephropathy. The patient ought to keep up a HbA1C of under 7 to secure his kidneys. You ought to begin the patient on an ACE inhibitor to secure his kidneys. The greater part of the above are valid.

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Patient #2 Your next patient is a 43 year old lady with a six year history of sort 2 diabetes. A pee plunge indicates follow protein and a spot AM pee alb/cr proportion is .039. Her circulatory strain is 135/80 and her HbA1C is 6.7.

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Which is (are) not genuine? You ought to check the patient\'s serum creatinine and potassium. You ought to begin the patient on an ACE inhibitor if her K+ and Cr are alright. You ought to check a 24 hour pee for aggregate protein and creatinine freedom. The patient has unmistakable diabetic nephropathy and ought to be alluded to a nephrologist.

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Case #3 Your last patient is a 60 year old with HTN, dyslipidemia and recently analyzed sort 2 diabetes. A pee plunge indicates 2+ protein. He has a fever and his HbA1C is 10.3. His pulse is 140/88. He is taking HCTZ and glipizide.

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Which is (are) valid? You ought to get the patient\'s diabetes under better control before rechecking his pee. A fever won\'t bring about proteinuria. The patient\'s pulse is under great control. You ought to check the patient\'s potassium and creatinine.

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Case #3 Three months after the fact with work out, metformin and enalapril your patient\'s HbA1C is presently 7.5 and his circulatory strain is 135/85. A pee plunge now indicates 1+ protein.

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Which is (are) valid? You ought to check a 24 hour pee for aggregate protein and cr. cl. A spot AM pee egg whites/creatinine proportion corresponds well with a 24 hour pee for aggregate protein The patient likely as of now has diabetic nephropathy and ought to be alluded to a nephrologist.

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Use the Algorithm! Check all your diabetic patients every year for renal infection . Help your diabetic patients\' secure their kidneys by helping them monitor their diabetes. Help your diabetic patients secure their kidneys by helping them monitor their pulse.

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