chronic kidney disease ckd and diabetes

1. Chronic Kidney Disease (CKD) and Diabetes June 20, 2007 Alfred K. Cheung, M.D. University of Utah

3. 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)

7. 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

8. 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

9. Stages of CKD

14. 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

15. 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

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

21. 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

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

24. Systemic Complications of CKD Hypertension Cardiovascular disease Anemia Calcium-phosphorus-parathyroid

25. American Heart Association Patients with CKD Should be considered as highest-risk group for CVD Should be treated as such

26. Left Ventricular Hypertrophy in CKD

27. Erythropoietin Stimulating Agent in CKD Administration (SQ q 1-4 wk) Epoietin-a (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

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

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

33. 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 mL/min

34. 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