William Vega-Ocasio MD. Internal Medicine - Nephrology Centro Renal Hospital Menonita Cayey 787-535-1001 Ext. 5503 [email protected]

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

[email protected]@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


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


CarbohydratesLoad

Increased Transforming Growth factor

Angiotensin Platelet Derived Growth factor

Abnormally Regulated Thromboxanes and Endothelins

Microvascular Damage

Insulin DeficiencyHyperglycemia

HEART

VASCULAR SYSTEM

KIDNEY


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


HyperglycemiaHyperglycemia

NephropathyNephropathy

ESRDESRD


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




Nutritional Management of Diabetics with advance Renal Disease


HyperglycemiaHyperglycemia

NephropathyNephropathy

ESRDESRD

Progression of Disease

Regression of Disease

National Kidney Foundation


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


Up to Date ® Database ;ADA position Statement : Nephropathy in diabetes


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



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


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



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


STOP !!!STOP !!!


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 ?


……low protein diets may actually harm this low protein diets may actually harm this population, primarily by aggravating population, primarily by aggravating malnutrition….malnutrition….


……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..


……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%.


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




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


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


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 !!!

Documents

William Vega-Ocasio MD. Internal Medicine - Nephrology Centro Renal Hospital Menonita Cayey 787-535-1001 Ext. 5503 [email protected]