practical tips for managing the mist of renal disease

Practical Tips for Practical Tips for Managing the Mist of Managing the Mist of

Renal DiseaseRenal Disease

Christine LogarChristine LogarAssistant Professor, NephrologyAssistant Professor, Nephrology

University of WashingtonUniversity of Washington

What is diabetic kidney disease?What is diabetic kidney disease?

A microvascular complication of diabetes A microvascular complication of diabetes marked by marked by proteinuriaproteinuria and a decline in renal and a decline in renal function, progressing to renal failurefunction, progressing to renal failure

A big problemA big problem

OutlineOutline

Kidney 101Kidney 101Epidemiology of Diabetes and Kidney diseaseEpidemiology of Diabetes and Kidney diseasePathophysiologyPathophysiologyRisk factors for Development and progressionRisk factors for Development and progressionPrevention/TreatmentPrevention/Treatment

Specific issues in diabetics with CKDSpecific issues in diabetics with CKDDiabetics and DialysisDiabetics and Dialysis

What do the kidneys do?What do the kidneys do?

Your kidneys are sophisticated filtersYour kidneys are sophisticated filters-- eliminate waste and toxinseliminate waste and toxins-- eliminate or conserve fluideliminate or conserve fluid-- control the acidity of the bloodcontrol the acidity of the blood-- help to make blood cells andhelp to make blood cells and

control bone developmentcontrol bone development-- control blood pressurecontrol blood pressure

The The nephronnephron

Each Each nephronnephron has two parts:has two parts:1) 1) GlomerulusGlomerulus –– the nonthe non--selective filterselective filter2) The tubules 2) The tubules –– where the urine concentration and where the urine concentration and

composition is determinedcomposition is determined

Some kidney diseases primarily affect the Some kidney diseases primarily affect the glomerulusglomerulus, and , and others the tubules. However by the time you reach end others the tubules. However by the time you reach end stage kidney disease, both are damagedstage kidney disease, both are damaged

Kidney diseasesKidney diseasesDiseases that affect the Diseases that affect the GlomerulusGlomerulus

DiabetesDiabetesIgAIgA nephropathynephropathy ( ( glomerulonephritisglomerulonephritis))Focal Segmental Focal Segmental GlomerulosclerosisGlomerulosclerosis (FSGS)(FSGS)LupusLupus

Diseases that affect the tubulesDiseases that affect the tubulesPolycystic kidney diseasePolycystic kidney diseaseChronic interstitial nephritisChronic interstitial nephritisChronic Lithium toxicityChronic Lithium toxicity


A microvascular complication of diabetes A microvascular complication of diabetes marked by marked by proteinuriaproteinuria and a decline in renal and a decline in renal function (GFR), progressing to renal failure function (GFR), progressing to renal failure (CKD and ESRD)(CKD and ESRD)


Definition of chronic kidney disease Definition of chronic kidney disease (CKD)(CKD)

Structural or functional abnormalities of the Structural or functional abnormalities of the kidney for kidney for ≥≥ 3 months, with or without a 3 months, with or without a decreased GFR. Abnormalities may be detected decreased GFR. Abnormalities may be detected by renal imaging, urinalysis, blood tests, or renal by renal imaging, urinalysis, blood tests, or renal pathology.pathology.

OROR

GFR < 60 mL/min/1.73 mGFR < 60 mL/min/1.73 m22 for for ≥≥ 3 months3 months

DO NOT USE FOR INPATIENTSWill only report an exact number if < 60

85 85 yoyo female with female with creatininecreatinine 1.01.0

30yo African American 30yo African American male with male with creatininecreatinine 1.5

eGFR 57

eGFR 711.5

Neither of these patients may actually have any kidney disease…

GFR norms by ageGFR norms by age

PrevalencePrevalence

GFR calculated by MDRD equation

GlomerularGlomerular filtration rate (GFR)filtration rate (GFR)

The goodThe good……Identify patients Identify patients additional patients at risk additional patients at risk for kidney disease ( < 60) for kidney disease ( < 60) and CKD complicationsand CKD complications

Identify patients at risk Identify patients at risk for medication dosing for medication dosing complications complications

The badThe bad……Not for inpatientsNot for inpatients

Not great at extremes of Not great at extremes of age or weight (mm)age or weight (mm)

Not for patients with Not for patients with relatively preserved renal relatively preserved renal function (function (eGFReGFR > 60 is > 60 is less accurate)less accurate)

A normal GFR ( > 60) does not mean that the patient does not have kidney disease

Classification of CKDClassification of CKD

StageStage DescriptionDescriptionGFRGFR

(mL/min/1.73m(mL/min/1.73m22))

11 Kidney damage, normal Kidney damage, normal GFRGFR ≥≥ 9090

22 Kidney damage, mild Kidney damage, mild decrease GFRdecrease GFR 6060--8989

33 Moderate decrease GFRModerate decrease GFR 3030--5959

44 Severe decrease GFRSevere decrease GFR 1515--2929

55 Kidney Failure (ESRD)Kidney Failure (ESRD) <15 (or dialysis)<15 (or dialysis)

Classification of CKDClassification of CKD

StageStage DescriptionDescriptionGFRGFR

(mL/min/1.73m(mL/min/1.73m22))

11 Kidney damage, normal Kidney damage, normal GFRGFR ≥≥ 9090

22 Kidney damage, mild Kidney damage, mild decrease GFRdecrease GFR 6060--8989

33 Moderate decrease GFRModerate decrease GFR 3030--5959

44 Severe decrease GFRSevere decrease GFR 1515--2929

55 Kidney FailureKidney Failure <15 (or dialysis)<15 (or dialysis)

Diabetes

+ microalbuminuria

+macroalbuminuria

Definition of albumin excretionDefinition of albumin excretion

Spot collection 24hr Timed collection

(mg/g creatinine) (mg/ 24hr) ( microgram/min)

Normal < 30 < 30 < 20

Microalbuminuria 30-300 30-300 20-200

Macroalbuminuria > 300 > 300 > 200

Overt nephropathy > 500 (protein) > 500

Nephrotic > 3500 (protein) > 3500

OutlineOutline

Kidney 101Kidney 101Epidemiology of Diabetes and Kidney diseaseEpidemiology of Diabetes and Kidney disease

PathophysiologyPathophysiologyRisk factors for Development and progressionRisk factors for Development and progressionPrevention/TreatmentPrevention/Treatment


EpidemiologyEpidemiology

World Wide 170World Wide 170--250 million people have DM, 50+ million have 250 million people have DM, 50+ million have CKD*CKD*

7% of the US population has DM7% of the US population has DM90+% are Type II DM90+% are Type II DM30+% don30+% don’’t know that they have DMt know that they have DM

11% of the US Population has CKD or ESRD11% of the US Population has CKD or ESRDabout 1about 1--2% of this 11% has ESRD2% of this 11% has ESRD

500,000 patients on dialysis, projected to 500,000 patients on dialysis, projected to increase to 610,000 by 2010increase to 610,000 by 2010

KDOQI 2007

EpidemiologyEpidemiology

Diabetes is the leading cause of CKD in developed Diabetes is the leading cause of CKD in developed countries, and rising in developing countries.countries, and rising in developing countries.

In the US,In the US,43% of diabetics have microalbuminuria43% of diabetics have microalbuminuria8% have 8% have macroalbuminuriamacroalbuminuria

Diabetes accounts for 45% of ESRD, up from 18% in Diabetes accounts for 45% of ESRD, up from 18% in 19801980

USRDS 2004

This is a big problemThis is a big problem

Approach to these patients is multifaceted.Approach to these patients is multifaceted.

Requires many levels of health care providers to Requires many levels of health care providers to work together, integrated care, not organ system work together, integrated care, not organ system based.based.

Steno study of intensive Steno study of intensive managmentmanagment

OutlineOutline



Stages of DKD for Type I diabeticsStages of DKD for Type I diabetics

Stage 1 Stage 1 –– HyperfiltrationHyperfiltration (GFR increases) (GFR increases) Stage 2 Stage 2 –– Silent thickening of the GBM and increase in Silent thickening of the GBM and increase in mesangialmesangial

volumevolumeStage 3 Stage 3 –– microalbuminuriamicroalbuminuria

usually occurs after 6usually occurs after 6--15 years of diabetes15 years of diabetesGFR may be elevated or normalGFR may be elevated or normalBP usually increases in this stage but may remain in the BP usually increases in this stage but may remain in the

““normalnormal”” levellevelincrease in GBM thickness and increase in GBM thickness and mesangialmesangial volumevolume

Stage 4 Stage 4 –– rising rising albuminuriaalbuminuria, overt , overt proteinuriaproteinuriaHTN is well establishedHTN is well establishedProteinuriaProteinuria increases by 15increases by 15--40% per year (average is 20% )40% per year (average is 20% )GFR starts to fall, rapidly (10 ml/min/year)GFR starts to fall, rapidly (10 ml/min/year)

Stage 5 Stage 5 –– ESRD developsESRD develops

Am J Nephrol 2005; 25:77-94

OutlineOutline



Susceptibility to diabetic Susceptibility to diabetic nephropathynephropathy

Poor glycemic controlPoor glycemic controlEthnicityEthnicity

Native Am > Mexican Am > African Am > CaucasianNative Am > Mexican Am > African Am > Caucasian

GenderGenderMale > Female in type I and IIMale > Female in type I and II

AgeAgeHigher risk of type I if diagnosed between 12Higher risk of type I if diagnosed between 12--20 20 yoyo as as opposed to before age 12opposed to before age 12Higher risk of type II if diagnosed after age 50 compared to Higher risk of type II if diagnosed after age 50 compared to before age 40before age 40

Adapted in part from Table 1. KI 2003; 64, p.371

Risk Factors for ProgressionRisk Factors for Progression

Underlying disease Underlying disease activity activity

HypertensionHypertension

ProteinuriaProteinuria

Exposure to Exposure to NephrotoxinsNephrotoxins

Urinary obstruction or Urinary obstruction or refluxreflux

HyperlipidemiaHyperlipidemia

Chronic anemiaChronic anemia

Cigarette smokingCigarette smoking

ObesityObesity

Interventions to prevent or slow the Interventions to prevent or slow the progression of diabetic nephropathyprogression of diabetic nephropathy

Glycemic controlGlycemic controlBlood pressure controlBlood pressure controlControl Control proteinuriaproteinuria

Use of RAAS blockersUse of RAAS blockers

Protein restriction (when all else fails to Protein restriction (when all else fails to decrease decrease proteinuriaproteinuria))

practical tips for managing the mist of renal disease

Documents