Diabetes Care in Renal Diabetes Care in Renal DiseaseDisease

Dr. F. Boutros

OverviewOverview

Diabetes/Renal program at the SGHDiabetes updateTreatment according to GFRClinical questions

Our ProgramOur Program

Started in 2001Diabetes/CKD clinicDiabetes/Dialysis clinicVolume: 30-40 patients/week2001 4 team members2007 15 team members

Diabetic NephropathyDiabetic Nephropathy

I Renal hypertrophyII Histological changesIII MicroalbuminuriaIV ProteinuriaV End stage renal disease

ManagementManagement

Blood sugar controlBlood pressure controlLipid control

ClassificationClassification

Type 1Type 2Gestational DiabetesSecondary Diabetes

Type 1Type 1Pancreatic FailurePancreatic Failure

Auto-immune diseaseBeta-cell destructionAbsolute insulin deficiencyInsulin is the only treatmentTransplant

Insulin in Type 1Insulin in Type 1

MDI(Multiple Daily Injections)

Insulin Pump

MDIMDI

Basal InsulinLantusLevemirNPH

Meal InsulinNovo rapidHumalogToronto/Regular

Insulin PumpInsulin Pump

Medtronic pumpNovo rapid or HumalogDose calculationPatient selectionCostCoverage

Type 1 in Renal DiseaseType 1 in Renal Disease

Use the right insulinHypoglycemiaEffect of Dialysis

PDHemodialysis

Optimize before kidney transplantEndocrine referralPump referral

Type 2Type 2

Metabolic disease/syndromeInsulin ResistanceRelative insulin deficiencyOral agentsInsulin

Oral agentsOral agents

MetforminTZDs (Avandia—Actos)Secretagogues

GluconormDiamicronGlyburide

AcarboseDPP IV inhibitors

MetforminMetformin

Inhibits hepatic gluconeogenesisImproves insulin resistanceGI upsetLactic AcidosisGFR >60 OK

50-60 Watch<50 Stop

TZDTZDAvandia&ActosAvandia&Actos

Bind to PPAR-gammaInsulin sensitizationCan be used in kidney diseaseEdemaVolume statusCHF

GluconormGluconorm

Insulin secretionShort actingLess HypoglycemiaCan be used in kidney diseaseLiver excretion

Glyburide/DiamicronGlyburide/Diamicron

Insulin secretionRisk of HypoglycemiaRenal ExcretionGFR<60 Stop

Insulin in Type 2Insulin in Type 2

Best option in renal diseaseTwice/dayPremix Insulin

30/70Novo mix 30Humalog mix 25Humalog mix 50

MDIInsulin Pump

ConclusionConclusion

Type 1Type 1

MDIInsulin Pump

Type 2Type 2GFR>60GFR>60

MetforminAvandia or ActosGluconorm/Glyburide/DiamicronTwice/day Insulin

Type 2Type 2GFR 50GFR 50--6060

Watch closelyIf poor control go to insulin

Type 2Type 2GFR<50GFR<50

If poor control go to InsulinAvandia or Actos

watch volume statuswatch for CHF

Gluconorm

Type 2Type 2DialysisDialysis

InsulinGluconorm??Avandia/Actos??

TransplantTransplant

Insulin

QuestionsQuestions