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Continuing Education:
Renal and Diabetes
Alisa McAleer, Dietetic Intern
December 15, 2014
Southern Regional Medical Center
Outline
• Chronic Kidney Disease and Diabetes
• Recommendations & guidelines: Glycemic Control and Protein
• For the pract...
Chronic Kidney Disease (CKD)
• CKD definition: Abnormalities of kidney structure or function, present for
> 3 months, with...
Diabetic Nephropathy
• Diabetic nephropathy (DN)
• Glomerular hypertrophy
• Transient hyperfiltration
• Proteinuria
• Rena...
Kidneyabc.com
Diabetic
Nephropathy
Albuminuria
Stages
• Stage – A1
• <30 mg/24hrs (Normal)
• Stage – A2
• 30-300 mg/24hrs (Moderately increased
albumin urina...
Renal & Diabetes
Current Regulations and Guidelines
Glycemic Control
• Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation
...
Low Protein Diet
• Low-Protein and Diabetic
Nephropathy: Meta-analyses
• LPD – 0.6-0.8 g/kg/day
• Control – 1-1.6g/kg/day
...
CKD: Protein Intake for Diabetic
Nephropathy:
Academy Supported Evidence
• WHAT ARE THE PROTEIN REQUIREMENTS TO MINIMIZE D...
Renal and Diabetes
The RDN
RDN Skill Level
• Competent, proficient and expert
• Certificate of Training Program in CKD Nutrition Management
• CDR’s B...
Diet Intervention
• Kidney disease
• Uremia
• Hypertension
• Edema
• Hyperkalemia
• Hyperlipidemia
• Blood glucose
Patient Education and Counseling
• Obesity
• Increased risk for DN
• Hyperlipidemia
• Coronary disease – lipid management
...
Patient Education and Counseling
• Carbohydrate Counting
• Keep cholesterol level under control
• Limit protein to a healt...
Summary
• Early detection
• Proper screening
• Management
References
• Academy of Nutrition and Dietetics Evidence Analysis Library. (n.d.). CKD: protein intake for diabetic nephro...
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Renal and Diabetes Continuing Education Presentation

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Renal and Diabetes Continuing Education Presentation

  1. 1. Continuing Education: Renal and Diabetes Alisa McAleer, Dietetic Intern December 15, 2014 Southern Regional Medical Center
  2. 2. Outline • Chronic Kidney Disease and Diabetes • Recommendations & guidelines: Glycemic Control and Protein • For the practicing RDN • Patient education and counseling
  3. 3. Chronic Kidney Disease (CKD) • CKD definition: Abnormalities of kidney structure or function, present for > 3 months, with implications for health • The most common cause of kidney failure ??? • Latter stages of Chronic Kidney Disease (CKD) • 35%- Adults with Diabetes
  4. 4. Diabetic Nephropathy • Diabetic nephropathy (DN) • Glomerular hypertrophy • Transient hyperfiltration • Proteinuria • Renal fibrosis • Decreased glomerular filtration rate (GFR) • Prevalence • African Americans, Asians, Native Americans • Risk factors • Poor glycemic control, hypertension, tobacco use, age of onset
  5. 5. Kidneyabc.com Diabetic Nephropathy
  6. 6. Albuminuria Stages • Stage – A1 • <30 mg/24hrs (Normal) • Stage – A2 • 30-300 mg/24hrs (Moderately increased albumin urinary excretion) • Stage – A3 • >300 mg/24hrs (Severely increased albumin urinary excretion) Screening • Type 1 Diabetes • 5 years after diagnosis • Type 2 Diabetes • Upon initial diagnoses
  7. 7. Renal & Diabetes Current Regulations and Guidelines
  8. 8. Glycemic Control • Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) • Subjects (randomized) • Tight glycemic control (Hgb A1c <6.5%) • Standard control • 10% risk reduction in macro/microvascular events • 21% reduction in nephropathy • Meta-analysis published in 2012 • Tight glycemic control reduces overall albuminuria • Target goal A1c <7%
  9. 9. Low Protein Diet • Low-Protein and Diabetic Nephropathy: Meta-analyses • LPD – 0.6-0.8 g/kg/day • Control – 1-1.6g/kg/day • Actual Protein Intake Ratio (APIR) • Protein intake • Diet compliance • Protective effects • Improved eGFR & proteinuria • No negative impact on glycemic control • Sustainable intervention is key!
  10. 10. CKD: Protein Intake for Diabetic Nephropathy: Academy Supported Evidence • WHAT ARE THE PROTEIN REQUIREMENTS TO MINIMIZE DISEASE PROGRESSION WHILE MAINTAINING ADEQUATE NUTRITION STATUS IN ADULT NON-DIALYZED PATIENTS WITH DIABETIC NEPHROPATHY? • CKD: Protein Intake for Diabetic Nephropathy • For adults with diabetic nephropathy, the RD should recommend or prescribe a protein- controlled diet providing 0.8g to 0.9g of protein per kg of body weight per day. Providing dietary protein at a level of 0.7g per kg of body weight per day may result in hypoalbuminemia and potential risk of malnutrition. Research reports that protein-restricted diets improved microalbuminuria. • American Diabetes Association: 0.8g/kg
  11. 11. Renal and Diabetes The RDN
  12. 12. RDN Skill Level • Competent, proficient and expert • Certificate of Training Program in CKD Nutrition Management • CDR’s Board Certification in Renal Nutrition
  13. 13. Diet Intervention • Kidney disease • Uremia • Hypertension • Edema • Hyperkalemia • Hyperlipidemia • Blood glucose
  14. 14. Patient Education and Counseling • Obesity • Increased risk for DN • Hyperlipidemia • Coronary disease – lipid management • Vitamin D therapy • RAAS and albuminuria • Antioxidants • Not recommended as a treatment
  15. 15. Patient Education and Counseling • Carbohydrate Counting • Keep cholesterol level under control • Limit protein to a healthy level based on individualized recommendations (CAUTION) • Limit sodium intake, <2 grams
  16. 16. Summary • Early detection • Proper screening • Management
  17. 17. References • Academy of Nutrition and Dietetics Evidence Analysis Library. (n.d.). CKD: protein intake for diabetic nephropathy. Retrieved December 7, 2014, from andeal.org: http://www.andeal.org/template.cfm?template=guide_summary&key=2409 • American Diabetes Association. (2014). Nephropathy in diabetics (Position statement). Diabetes Care, 37(12). • Franz, M. J., Powers, M. A., Leontos, C., Holzmeister, Kulkarni, K., Monk, A., . . . Gradwell, E. (2010, December). The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. Journal of the American Dietetic Association, 110(12), 1852-1889. doi: http://dx.doi.org/10.1016/j.jada.2010.09.014 • Kent, P. S., McCarthy, M. P., Burrowes, McCann, L., Pavlinac, J., Goeddeke-Merickel, C. M., . . . Benner, D. (2014). Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 standards of practice and standards of professional performance for Registered Dietitian Nutritionists (competent, proficient and expert) in nephrology nutrition. Journal of the Academy of Nutrition and Dietetics, 1448-1503. • Kowalski, A., Krikorian, A., & Lerma, E. V. (2014). Diabetic nephropathy for the primary care provider: new understandings on early detection and treatment. The Ochsner Journal, 14(3), 369-379. • Lowth, M. (2013). Chronic kidney disease - an update. Practice Nurse, 43(1), 34-39. • Mahan, K. E.-S. (2012). Krause's food and the nutrition care process. St. Louis, MO: Elsevier. • Nezu, U., Kamiyama, H., Kondo, Y., Sakuma, M., Morimoto, T., & Ueda, S. (2013, April 25). Effect of low-protein diet on kidney function in diabetic nephropathy: meta-analysis of randomised controlled trials. BMJ Open. doi:10.1136/bmjopen-2013-002934 • Steves, P. (2013). Evaluation and managment of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Annals of Internal Medicine, 825-830. • Supplement: summary of recommendation statements. (2013). Kidney International, 3, 5-14. doi:10.1038/kisup.2012.77

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