1 / 43

Comprehensive Treatment Strategies for Diabetic Nephropathy - Reviews & Recommendations

Discover the latest insights on treating diabetic renal disease with hypertension. Learn about microalbuminuria definitions, treatment targets, and effective interventions. Get expert advice and research findings for optimal patient care.

henrycjones
Download Presentation

Comprehensive Treatment Strategies for Diabetic Nephropathy - Reviews & Recommendations

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Diabetes Mellitus Hart, Nieren & Hypertensie

  2. Microalbuminurie bij Diabetes

  3. Definitions of Microalbuminuria and Macroalbuminuria AER=Albumin excretion rate CR# =creatinine

  4. Behandeling van Diabetes moet dus in hoge mate zijn gericht op preventie van cardiovasculaire ziekte . . .

  5. Treatment Targets for Diabetic Renal Disease With Hypertension GLUCOSE GLUCOSE BP BP LIPIDS LIPIDS

  6. 130 134 138 142 146 150 154 170 180 Meta Analysis: Lower SystolicBPResults in Slower Rates of Decline in GFR in Diabetics and Non-Diabetics SBP (mmHg) 0 -2 r = 0.69; P < .05 -4 -6 Untreated HTN GFR (mL/min/year) -8 -10 -12 -14 Parving HH, et al. Br Med J. 1989. Moschio G, et al. N Engl J Med. 1996. Viberti GC, et al. JAMA. 1993. Bakris GL, et al. Kidney Int. 1996. Klahr S, et al. N Eng J Med. 1994. Bakris GL. Hypertension. 1997. Hebert L, et al. Kidney Int. 1994. The GISEN Group. Lancet. 1997. Lebovitz H, et al. Kidney Int. 1994. Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661.

  7. Behandeling Microalbuminurie bij DM~ 2e-doel RR: 120-130/<80 mmHg • ACEi met diureticum (eg. Captopril/HCT of Lisinopril/HCT) • 2e middel op indicatie (eg. BB bij angina pectoris) • 2-3e middel: Spironolacton, (z.n. + kaliumbeperkt dieet of HCT/chloortalidon of sorbisterit) • 3-4e middel: Allopurinol

  8. Consultatie van of verwijzing naar detweede lijn is aangewezen bij • twijfel over de diagnose, • problemen bij de glycemische instelling, • problemen bij behandeling van risicofactoren, • het onvoldoende onder controle krijgen van de gevolgen van complicaties • zwangerschap(swens). LTA DM-II, 2012

  9. From Dr J Vora

  10. DM-II • Losartan verhoogt de incidentie van microalbuminurie • RR-verlaging < 120 mmHg systolisch induceert meer sterfte • Vitamine-D vermindert microalbuminurie • Intensieve behandeling hyperglycemie in de initiële fase van DM-I/II reduceert nefropathie en CVR • Mortaliteit stijgt bij HbA1c > 85 en < 42 mmol/mol • Intermitterende episodes van acute nierinsufficientie verslechteren de lange termijn prognose

  11. Results Of 5927 allopurinol initiators and 5927 matched comparators, 654 and 718, respectively, died during the follow-up (mean=2.9 years). The baseline characteristics were well balanced in the two groups, including the prevalence of gout in each group (84%). Allopurinol initiation was associated with a lower risk of all-cause mortality (matched HR 0.89 (95% CI 0.80 to 0.99)). When we limited the analysis to those with gout, the corresponding HR was 0.81 (95% CI 0.70 to 0.92). Allopurinol initiation and all-cause mortality in the general population http://dx.doi.org/10.1136 annrheumdis-2014-205269

  12. Urinezuur is een cardiovasculaire risicofactor

  13. Allopurinol bij DM • Vermindert insuline resistentie • Verlaagt CRP • Vertraagt Atherosclerose • Vermindert Microalbuminurie • Vermindert Chronische nierschade • Vermindert Linkerventrikelhypertrofie • Vermindert Oxidatieve stress

  14. Allopurinol risico’s • Acute allergische reactie 4,7 promille • Gerelateerde mortaliteit 0,4 promille • Heupfractuur Odds Ratio (OR) 1,07 • Lager risico op Hartinfarct: OR 0,73 OR 0,52, dosis en duur afhankelijk • Atriumfibrilleren: OR 0,73 JAMA Intern Med. 2015;175(9):1550. Archives of Osteoporosis 2015, 10:36 annrheumdis-2012-202972 heartjnl-2014-306670 annrheumdis-2012

  15. Metformine

  16. Metformine risico’s • Bij eGFR<15: Mortaliteit OR 1,35 • Lactaat acidose 1,6 vs 1,3/100jaar (n.s.) • Bij eGFR > 30 ml/min/1,73m2: nuttig en veilig • Bij eGFR 15- 30 ml/min/1,73m2: waarschijnlijk nuttig en veilig.

  17. Effectiveness and safety of metformin in 51675 patients with type 2 diabetes and different levels of renal function: a cohort study from the Swedish National Diabetes Register. BMJ Open. 2012 Jul 13;2(4).

  18. Verschillen tussen ACE-remmers

  19. CV Mortality in General Population (GP) & Dialysis Patients, By Race Sarnak MJ, Levey AS. Semin Dial. 1999;12:69-76.

  20. Tot slot, praktisch: . . .

  21. Mijn behandelingsstrategie bij: diabetes + chronische nierziekte(≥ microalbuminurie) ± hypertensie • ≥3x1uur bewegen/week; roken -; gewicht ; voeding. • Bloeddruk ≤125/75 mmHg • Start met een ACE-remmer, liefst een combinatiepil met een lage dosis diureticum ! • +/-Zoutarm dieet (<6 g NaCl/d) • Doseren totdat proteinuria ≤ 0,5 g/dag is • Behandel dislipidemie (LDL <2,5 mmol/L, Trigl ≤ 2,0) • HbA1C < 60 mm/mP C Chang, RZZ

  22. 5 1 p<0.0001 17% decrease per 10 mmHg decrement in BP 0 . 5 1 1 0 1 2 0 1 3 0 1 4 0 1 5 0 1 6 0 1 7 0 UKPDS: Relationship Between BP Control And Diabetes-Related Deaths Hazard ratio Mean systolic blood pressure (mmHg) Adler AI, et al. BMJ. 2000;321:412-419. Reprinted by permission, BMJ Publishing Group.

  23. Risk of Ischemic Heart Disease Related to SBP and Microalbuminuria N=2,085; 10 year follow-up Borch-Johnsen K, et al. Arterioscler Thromb Vasc Biol. 1999;19(8):1992-1997.

  24. Relative Importance of CV Risk Factors in Diabetes 12 10.0 10 8 6.5 Odds Ratio 6 3.2 4 2.3 2 0 Microalbuminuria Smoking Diastolic BP Cholesterol Eastman RC, Keen H. Lancet 1997;350 Suppl 1:29-32.

  25. Diabetes and Chronic Renal Disease as CV Risk

  26. Behandeling van Diabetes moet dus in hoge mate zijn gericht op preventie van cardiovasculaire ziekte . . .

  27. Cardiovasculaire Preventie in Diabetes

  28. Vascular Protection: Glycaemic Control

  29. Glycaemic Control for Vascular Protection: after all Patients are on ACE Inhibitor, ASA and Lipid Control (statin) - 5 Fatal and Non Fatal Myocardial Infarction 14% decrease per 1% decrement in HbA1c p<0.0001 CDA 2003 Glycaemic Targets A1c  7% for most patients A1c  6% when safely achievable Hazard ratio 1 0 . 5 0 5 6 7 8 9 1 0 1 1 Updated mean HbA1c UKPDS 35. BMJ 2000; 321: 405-12.

  30. Vascular Protection:Diabetes and Control of Hypertension

  31. Treatment Targets for Diabetic Renal Disease With Hypertension GLUCOSE GLUCOSE BP BP LIPIDS LIPIDS

  32. 8 7 6 5 CVmortalityrisk 4 3 2 1 0 115/75 135/85 155/95 175/105 SBP/DBP (mm Hg) CV Mortality Risk Doubles withEach 20/10 mm Hg BP Increment* *Individuals aged 40-69 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure Lewington S, et al. Lancet. 2002; 60:1903-1913. JNC VII. JAMA. 2003.

  33. Goal BP Recommendations for Patients with DM or Renal Disease Renal Disease & Proteinuria >1g (JNC VI)

  34. From Dr J Vora

  35. Management of Chronic Renal Disease: Initial Diet Therapy • For patients with modest renal insufficiency, reduce intake of high biological quality protein* intake of 1 gm/kg body weight/day • For patients with marked renal insufficiency, reduce dietary protein intake to 0.8 gm/kg body weight/day • Restrict dietary sodium intake to 4-6 gm/day • Avoid foods rich in potassium *high biological quality proteins are those rich in essential amino acids

  36. Impact of Blood Pressure Reduction on Mortality in Diabetes Mortality endpoints are: UK Prospective Diabetes Study (UKPDS) – “diabetes related deaths” Hypertension Optimal Treatment (HOT) Study – “cardiovascular deaths” in diabetics Turner RC, et al. BMJ. 1998;317:703-713. Hansson L, et al. Lancet. 1998;351:1755–1762.

  37. Diabetes and Hypertension 3.0% No DM 2.0% DM Annual Mortality 1.0% 0.0% <120 120- 140- 160- 180- >200 139 159 179 199 Systolic BP Stamler J, et al, Diabetes Care, 1993;16(2):434-444.

  38. Treatment Targets for Diabetic Renal Disease With Hypertension GLUCOSE GLUCOSE BP BP LIPIDS LIPIDS

More Related