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OPTA – Education Initiative

OPTA – Education Initiative. OPTA – Optimal Treatment of Renal Anaemia. OPTA – Optimal Treatment of Renal Anaemia. Existing Recommendations OPTA – Haemodialysis Patients OPTA – Therapy with Iron and Recombinant Human Erythropoietin

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OPTA – Education Initiative

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  1. OPTA – Education Initiative OPTA – Optimal Treatment of Renal Anaemia

  2. OPTA – Optimal Treatment of Renal Anaemia Existing Recommendations OPTA – Haemodialysis Patients OPTA – Therapy with Iron and Recombinant Human Erythropoietin OPTA – Influence of Inflammation/Infection on Anaemia Therapy OPTA – Patients with Chronic Kidney Disease

  3. OPTA – Rationale • European Best Practice Guidelines and KDOQI Guidelines provide scientific evidence on optimal treatment of renal anaemia. • European Surveys of Anaemia Management (ESAM I &II,PRESAM, TRESAM) and Dialysis Outcomes and Practice Patterns Study (DOPPS) demonstrate relevant gaps between standards of care of anaemia treatment and daily practice. • OPTA aims at transfering standards of care into daily practice and optimising efficacy and efficiency of anaemia therapy by focussing on major and minor factors influencing treatment of renal anaemia.

  4. OPTA – Optimal Treatment of Renal Anaemia • Optimal Treatment of Renal Anaemia in Diabetic Patientswith Chronic Kidney Disease • Faculty:W.H. Hörl, Austria • G. Ghirlanda, Italy • A. Bren, Slovenia • A. M. Castello, Spain • C. Hasslacher, Germany • J. Tapia, Sweden • C. Wanner, Germany

  5. Content • Introduction • Definition of diabetic kidney disease • Definitions of metabolic abnormalities • Definitions of abnormalities in albumin excretion • Anaemia and diabetic kidney disease • Anaemia definition and diagnosis • Anaemia treatment of DKD patients • Changes of laboratory and treatment aspects during progressionof DKD • Clinical practice management in DKD Stages

  6. Diabetes and Diabetic Kidney Disease (DKD) • Diabetes is the leading cause of CKD in developed countries and is rapidly increasing in developing countries • In Europe, Diabetes affects ~ 40 million people • Overall risk to develop DKD varies about 25–40% of type 1 and type 2 diabetic patients after 25 years of diabetes duration • Approximately 75% of people with diabetes die of CVD related causes (ADA* 2002) • Under-diagnosis of Diabetes and CKD leads to lostopportunities for prevention * American Diabetes Association

  7. Definitions of Diabetic Kidney Disease Definitions of abnormalities in albumin excretion Category Spot 24 hour Timed urine collection collection(mg/g creatinine) (mg/24h) (µg/minute) ACR AER Normo- albuminuria < 30 < 30 < 20 Micro-albuminuria 30–299 30–299 20–199 Macro- albuminuria ≥ 300 ≥ 300 ≥ 200 AER = Albumin Excretion Rate ACR= Albumin Creatinine Ratio Adapted from KDOQI-Guidelines

  8. Definitions of Diabetic Kidney Disease Likelihood of DKD according to eGFR and level of albuminuria eGFR CKD Normo- Micro- Macro-(ml/min) Stage albuminuria albuminuria albuminuria > 60 1 + 2 At risk Possible DKD DKD 30–60 3 Unlikely Possible DKD DKD DKD < 30 4 + 5 Unlikely Unlikely DKD DKD DKD In most patients with Diabetes, CKD is attributable to the diabetes if; -Macroalbuminuria is present OR -Microalbuminuria is present in presence of diabetic retinopathy, in type 1 diabetes of at least 10 years duration Adapted from KDOQI-Guidelines

  9. Chronic Kidney Disease not attributable to Diabetes • Recommendation • Other cause(s) of CKD should be considered in the presence of any of the following circumstances: • absence of diabetic retinopathy • slow or rapidly declining GFR • rapidly increasing proteinuria or nephrotic syndrome • refractory hypertension • presence of active urinary sediment (special attention to microhaematuria) • signs or symptoms of other systemic disease • greater than 30% reduction in GFR within 2–3 months after initiation of an ACE inhibitor or ARB treatment

  10. Definitions of abnormalities in albumin excretion Recommendation Screening for diabetic kidney disease should begin after: - 5 years of type 1 diabetes - at the diagnosis of type 2 diabetes,(due to inability to establish the onset of type 2 diabetes with certainty)

  11. Definitions of metabolic abnormalities Individuals at high risk of type 2 Diabetes Body Mass Index > 25 kg/m² Waist Hip Ratio > 1.0 (men) > 0.85 (women) Waist circumference > 102 cm -Type 2 Diabetes is frequently not diagnosed until complications appear -~one third of all people with diabetes may be undiagnosed

  12. Anaemia and Diabetic Kidney Disease • Target organ damage in patients with diabetes • Retina (diabetic retinopathy) • Kidney (diabetic nephropathy) • Peripheral nerves (diabetic polyneuropathy) • Heart (ischemic heart disease, cardiomyopathy,congestive heart failure) • Peripheral arteries (peripheral artery disease) ¹ Ritz, Haxen; Europ J Clin Invest 2005;35 (Suppl. 3):66–74.² Thomas MC et al., Diabetologia 2006;49:1151–1157.

  13. Anaemia and Diabetic Kidney Disease • Anaemia is a common complication of CKD affecting over half of all patients.¹ • Diabetes is the most common cause of CKD² and thereforeof renal anaemia. • Risk of developing anaemia is two to three times higher in diabeticsthan in CKD patients with comparable kidney function. • Diabetics display a higher incidence of anaemia in the earlier stagesof CKD. • Lower Hb-levels are linked with development/worsening ofdiabetic complications (retinopathy, diabetic nephropathy). ¹ US Renal Data System 2001² McClellan 2004

  14. Anaemia and Diabetic Kidney Disease • Possible mechanism of Anaemia in diabetic kidney disease • Decreased Epo production due to kidney interstitial fibrosis(a classical feature of diabetic kidney disease) • Decreased Epo release through autonomic neuropathy • Urinary losses of Epo associated with nephrotic range proteinuria • Shortened erythrocyte half life¹ • HIF-1α polymorphism in type 2 diabetic patients and hyperglycaemia • Iron malabsorption due to diabetic autonomic disease of the gut² • The HIF-factor one is subunit of HIF transcription factor, response to hypoxia ¹ Ritz, Haxen; Europ J Clin Invest 2005;35 (Suppl. 3):66–74. ² Thomas MC, Nat Clin Pract Nephrol 2007;3:20–30.

  15. Anaemia and Diabetic Kidney Disease Anaemia is more severe in chronic kidney disease patients with diabetes. Diabetic Non-diabeticpatients patients (n=19) (n=19) Age [years] 59 ± 11 56 ± 13 Sex [male/female]13 / 6 13 / 8 Serum creatinine [mg/dl] 3.5 ± 1.6 3.8 ± 1.5 Haemoglobin [g/dl]9.5 ± 2.1 11.2 ± 2.0* Serum erythropoietin [mU/ml] 19.8 ± 6.2 18.6 ± 5.6 HbA1c 7.6 ± 1.8 – Ishimura E et al, J Nephrol 1998;11:83–86.

  16. Anaemia and Diabetic Kidney Disease • Anaemia with erythropoietin deficiency occurs early in diabetic nephropathy • 53 patients with chronic kidney disease • – 27 type 1 diabetic patients with diabetic nephropathy • – 26 patients with glomerulonephritis • – serum creatinine < 180 µmol/l • Results • – 13/27 diabetic patients with anaemia Hb 10.6 ± 0.9 g/dl • – 0/26 glomerulonephritis patients Hb 13.7 ± 1.4 g/d Bosman DR et al., Diabetes Care 2001;24:495–499.

  17. Anaemia and Diabetic Kidney Disease Mean haemoglobin in different CKD groups in diabetic andnon-diabetic patients with renal disease 16 Non-diabetic patients (n=264) Diabetic patients (n= 204) 15 14 13 Mean Hb [g/dl] 12 11 10 9 CKD 1 and 2 CKD 3 CKD 4 und 5 Al-Khoury S et al, Diabetologia 2006;49:1183–1189.

  18. Anaemia and Diabetic Kidney Disease Haemoglobin distribution in type 2 diabetic patients at baseline 150 100 Number of participants 50 0 7 8 9 10 11 12 13 14 15 16 Haemoglobin g/L Mild anaemia (<13.8g/dL )is a risk factor for progression to ESRD in type II diabetes Mohanram A et al, Kidney Int 2004;66:1131–113.

  19. Anaemia and Diabetic Kidney Disease Clinical and biochemical characteristics of the patients groupedaccording to the degree of albuminuria EPO loss increases as protein loss increases Mojiminiyi OA et al., Diabet Med 2006;23:839–844.

  20. Anaemia and Diabetic Kidney Disease Prevalence of anaemia, stratified according to level of creatinine clearance and albuminuria in type 2 DM patients Thomas MC et al, Diabetologia 2006;49:1151–1157.

  21. Diagnosis of Anaemia – Recommendation I Patients should receive a diagnostic work-up for anaemia • when creatinine clearance falls below – 70 ml/min in men – 50 ml/min in women • when Hb-level falls below: – 11.5 g/dl in adult female patients1 – 13.5 g/dl in adult male patients1 – 12 g/dl in adult male patients aged > 701 – 11 g/dl in pre-pubertal subjects and pre-menopausal females2 – 12 g/dl in adult males and post-menopausal females2 1 Revised EBPGs, NDT 2004;19. 2 K/DOQI, Am J Kidney Dis 2001;37.

  22. Diagnosis of Anaemia – Recommendation II Diabetic patients should receive a diagnostic work-up for anaemia • with macroalbuminuria: eGFR > 60 ml/min • without macroalbuminuria: eGFR < 60 ml/min 1 Revised EBPGs, NDT 2004;19: 2 K/DOQI, Am J Kidney Dis 2001;37:

  23. Treatment of Anaemia – Recommendation Anaemia treatment of DKD patients: Target Hb-levels Anaemia treatment should be initiated when haemoglobinlevels fall below 11 g/dl and a value of 11 to 12 g/dl appearsto be the best option to aim at Anaemia should not be completely corrected in patientswith diabetic kidney disease. The target Hb level fordiabetic patients should not exceed 12 g/dl.¹ 1 Revised EBPGs, NDT 2004;19:??–-??.

  24. Changes of laboratory and treatment aspectsduring progression of DKD Glycemic control in diabetes and CKD during all stages of CKD HbA1c:< 7% Postprandial capillary glucose:90–130 mg/dl (5.0–7.2 mmol/l) Peak postprandial capillary glucose: < 180 mg/dl (<10 mmol/l)

  25. Changes of laboratory and treatment aspectsduring progression of DKD Glycemic control in diabetes and CKD during CKD stages 3–5 Patients in CKD increased risk for hypoglycemiastages 3–5: due to decreased clearance of insulin and impaired renal gluconeogenesis close self monitoring of glucose levels Recommendation: Patients with progressive DKD and on insulin treatment should be monitored closely in stages 3–5 due to higher risk of developing hypoglycaemia

  26. Risk Factor Management Risk factor management is the cornerstone of therapy in diabetickidney disease patients Intensive management of – hypertension – hyperglycaemia – dyslipidaemia – protein intake Revised EBPGs, NDT 2004;19:??–??.

  27. Clinical Practice Management in DKD Stages (1/2) • Laboratory Parameters Target levels monitoring frequency • Glycaemic control • HbA1c < 6.5 %* 3 monthly • Preprandial capillary 90–130 mg/dl 4 or more times daily** • plasma glucose (5.0–7.2 mmol/l) • Peak postprandial <180 mg/dl as needed*** • capillary plasma glucose† (<10.0 mmol/l) • Systolic/diastolic blood pressure < 130/80 mmHg • Cholesterol < 175 mg/dl • Triglycerides < 150 mg/dl (<1.7 mmol/l) • Non-HDL Cholesterol‡ < 130 mg/dl • LCL Cholesterol < 100 mg/dl (<2.6 mmol/l) • Option < 70 mg/dl • Proteinuria < 0.5 g/g creatinine • ACE-I or ARB irrespective of blood pressure • Aspirin 100 mg/day * Goals should be individualized. Certain populations (children, pregnant women, and elderly) require special considerations. More stringent glycaemic goals (i.e., a normal HbA1c, <6%) may further reduce complications at the cost of increased risk of hypoglycaemia. Less intensive glycaemic goals may be indicated in patients with severe or frequent hypoglycaemia. Postprandial glucose may be targeted if HbA1c goals are not met despite reaching preprandial glucose goals. **, if insulin treated *** helpful in patients with gastroparesis † Postprandial glucose measurements should be made 1–2 h after the beginning of the meal. ‡ Current NCEP/ATP III guidelines suggest that in patients with triglycerides >200 mg/dl, the “non-HDL cholesterol” (total cholesterol minus HDL) should be utilized (55).

  28. Clinical Practice Management in DKD Stages (2/2) Patient Care Target levels Monitoring frequency Retinopathy avoid annually Foot ulcers avoid daily visual inspection Smoking cessation

  29. Additional Relevant Factors • Nutritional status/Eating patterns • Weight history/healthy weight • Details of previous treatment programs • Nutrition and diabetic self-management education • Prior or current infections: particularly skin, foot, dental, genitourinary • Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, family history • Lifestyle/Lifestyle changes

  30. Summary • In patients with diabetic kidney disease, anaemia develops earlierand is more distinct. • Hb development should be monitored closely in patients withdiabetic kidney disease. • Anaemia is an independent risk factor for progression and mortalityin patients with diabetic kidney disease. • Anaemia treatment should be initiated when haemoglobin levels fallbelow 11 g/dl and a value of 11 to 12 g/dl appears to be the best option to aim at. The target Hb level for diabetic patients should not exceed 12 g/dl. • In patients with diabetic kidney disease, hypertension, hyperglycaemia and dyslipidaemia should be intensively managed. • Changes in life style of patients with diabetic kidney disease shouldbe encouraged even if success rate is limited.

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