Chronic Kidney Disease (CKD) and Diabetes Treatment

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MedicYatra provides the safe & best Chronic Kidney Disease (CKD) and Diabetes treatment and procedure at its affiliate & trusted hospitals & clinics in various metro cities of India, like Mumbai, Delhi, Bangalore, Chennai, Pune etc.Our Associate Board certified doctors are extensively trained and vastly experienced and have performed hundreds of such cases at our state of the art JCI accredited hospitals & Clinics. Our aim is to provide you the best of the services at the most affordable costs. Don't forget to say hi at info@medicyatra.com

Gesundheit & Medizin

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Chronic Kidney Disease
(CKD) and Diabetes

.

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Medic Yatra Kidney Foundation

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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)

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ESRD Incidence Counts and Rates
by Primary Diagnosis (USRDS, 2006)

Better CKD
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Glomerulus = filtering unit

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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

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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
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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
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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
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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

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Interventions to Slow CKD Progression
• Strong evidence
– Blood pressure control
– ACEI / ARB
– Glucose control in DM
• Weaker evidence
– Protein restriction
– Lowering LDL cholesterol

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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

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Email: enquiry@medicyatra.com

AKI Superimposed on CKD
• Dehydration
• BP too low
• Obstruction
• Contract dye
• Drugs
– Nephrotoxic or allergic or hemodynamic
– NSAID (including Cox-2 inhibitors)
– ACEI / ARB

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Systemic Complications of CKD

• Hypertension
• Cardiovascular disease
• Anemia
• Calcium-phosphorus-parathyroid

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American Heart Association

• Patients with CKD
– Should be considered as highest-risk group
for CVD
– Should be treated as such

Sarnak, Circ, 2004

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Left Ventricular Hypertrophy in CKD

Risk factors: HTN and Anemia
Copyright @ Forever Medic Online Pvt. Ltd 1999; Foley, KI, 1995
Levin, AJKD.

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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

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What is Renal Diet?
• Low sodium
• Low potassium
– What about DASH?
• Low phosphorus
– Adding glucose and fat targets?
• Should be individualized

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Symptoms of Uremia
• None or subtle
• Fatigue, lack of energy
• Anorexia (nausea/vomiting)
• Sleep disturbance
• Impaired cognitive function
• Impotence

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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@ Forever Medic Online Pvt. Ltd
Copyright mL/min

Email: enquiry@medicyatra.com

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

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1. Email: enquiry@medicyatra.com Chronic Kidney Disease (CKD) and Diabetes . Copyright @ Forever Medic Online Pvt. Ltd

2. Email: enquiry@medicyatra.com Medic Yatra Kidney Foundation Copyright @ Forever Medic Online Pvt. Ltd

3. Email: enquiry@medicyatra.com 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) Copyright @ Forever Medic Online Pvt. Ltd

4. Email: enquiry@medicyatra.com ESRD Incidence Counts and Rates by Primary Diagnosis (USRDS, 2006) Better CKD Copyright @ Forever Medic Online Pvt. Ltd Management?

5. Email: enquiry@medicyatra.com Glomerulus = filtering unit Copyright @ Forever Medic Online Pvt. Ltd

6. Email: enquiry@medicyatra.com Copyright @ Forever Medic Online Pvt. Ltd

7. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

8. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

9. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

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14. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

15. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

16. Email: enquiry@medicyatra.com Interventions to Slow CKD Progression • Strong evidence – Blood pressure control – ACEI / ARB – Glucose control in DM • Weaker evidence – Protein restriction – Lowering LDL cholesterol Copyright @ Forever Medic Online Pvt. Ltd

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21. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

22. Email: enquiry@medicyatra.com Copyright @ Forever Medic Online Pvt. Ltd

23. Email: enquiry@medicyatra.com AKI Superimposed on CKD • Dehydration • BP too low • Obstruction • Contract dye • Drugs – Nephrotoxic or allergic or hemodynamic – NSAID (including Cox-2 inhibitors) – ACEI / ARB Copyright @ Forever Medic Online Pvt. Ltd

24. Email: enquiry@medicyatra.com Systemic Complications of CKD • Hypertension • Cardiovascular disease • Anemia • Calcium-phosphorus-parathyroid Copyright @ Forever Medic Online Pvt. Ltd

25. Email: enquiry@medicyatra.com American Heart Association • Patients with CKD – Should be considered as highest-risk group for CVD – Should be treated as such Sarnak, Circ, 2004 Copyright @ Forever Medic Online Pvt. Ltd

26. Email: enquiry@medicyatra.com Left Ventricular Hypertrophy in CKD Risk factors: HTN and Anemia Copyright @ Forever Medic Online Pvt. Ltd 1999; Foley, KI, 1995 Levin, AJKD.

27. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

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30. Email: enquiry@medicyatra.com What is Renal Diet? • Low sodium • Low potassium – What about DASH? • Low phosphorus – Adding glucose and fat targets? • Should be individualized Copyright @ Forever Medic Online Pvt. Ltd

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32. Email: enquiry@medicyatra.com Symptoms of Uremia • None or subtle • Fatigue, lack of energy • Anorexia (nausea/vomiting) • Sleep disturbance • Impaired cognitive function • Impotence Copyright @ Forever Medic Online Pvt. Ltd

33. Email: enquiry@medicyatra.com 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@ Forever Medic Online Pvt. Ltd Copyright mL/min

34. Email: enquiry@medicyatra.com 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 Copyright @ Forever Medic Online Pvt. Ltd

35. Email: enquiry@medicyatra.com Copyright @ Forever Medic Online Pvt. Ltd