1 / 51

La gestione del paziente diabetico: bisogni, percorsi e strumenti

La gestione del paziente diabetico: bisogni, percorsi e strumenti Metodi per lo studio della nefropatia. Giuse pp e Penno Dipartimento di Medicina Clinica e Sperimentale Azienda Ospedaliera Universitaria di Pisa. Pisa, 28-30 OTTOBRE 2013. Key points.

cweingartner
Download Presentation

La gestione del paziente diabetico: bisogni, percorsi e strumenti

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. La gestione del paziente diabetico: bisogni, percorsi e strumenti Metodi per lo studio della nefropatia Giuseppe Penno Dipartimento di Medicina Clinica e Sperimentale Azienda Ospedaliera Universitaria di Pisa Pisa, 28-30 OTTOBRE 2013

  2. Key points Classification of chronic kidney disease (CKD) by albuminuria and eGFR

  3. KDIGO: Classification of Kidney Disease by albuminuria and Association with Adverse Outcomes Levey AS et al, Kidney Int 80: 17-28, 2011

  4. KDIGO: Classification of Kidney Disease by eGFR and Association with Adverse Outcomes Levey AS et al, Kidney Int 80: 17-28, 2011

  5. National Kidney Foundation’s (NKF’s) Kidney Disease Outcomes Quality Initiative (KDOQI) classification Stage 0 - No CKD Stage 1 CKD Stage 2 CKD Stage 3 CKD Stage 4 CKD Stage 5 CKD MDRD Levey AS et al, Ann Intern Med 139: 137-147, 2003

  6. Alberta Kidney Disease Network classification Risk category 0 Risk category 1 Risk category 2 Risk category 3 Risk category 4 MDRD Tonelli M et al, Ann Intern Med 154: 12-21, 2011

  7. Alberta Kidney Disease Network classification Tonelli M et al, Ann Intern Med 154: 12-21, 2011

  8. Take home This risk classification system identifies fewer patients as having advanced CKD than the NFK staging system This system could reduce unnecessary referral for care, at the cost of not referring or delaying referral for some patients who go on to develop ESRD or die

  9. Kidney Disease: Improving Global Outcomes (KDIGO) classification Low risk Moderate risk High risk Very high risk CKD- EPI KDIGO, Kidney IntSuppl 3: 1-150, 2013

  10. Kidney Disease: Improving Global Outcomes (KDIGO) classification Low risk Moderate risk High risk Very high risk KDIGO, Kidney IntSuppl 3: 1-150, 2013

  11. Kidney Disease: Improving Global Outcomes (KDIGO) classification Low risk Moderate risk High risk Very high risk KDIGO, Kidney IntSuppl 3: 1-150, 2013

  12. Key points Classification of chronic kidney disease (CKD) by eGFR and albuminuria Renal impairment is common. Every second/third patient in our clinic might have signs of renal impairment

  13. The RIACE (Renal Insufficiency and Cardiovascular Events) study 15,773 patients with type 2 diabetes from Italy MDRD * Plus “kidney damage” Penno G et al. J Hypertens 29: 1802-1809, 2011

  14. Renal dysfunction is common in patients with T2DM 1.7% 17.1% 12.0% 62.5% 6.7% The RIACE Study: 15,773 patients with T2DM No CKD CKD stage 1 CKD stage 2 CKD stage 3 CKD stages 4/5 Approximately 40% of patients with T2DM show signs of CKD (stages 1-5) Approximately 20% of patients with T2DM show signs of renalfailure (eGFR <60 ml/min/1.73 m2) Penno G et al. J Hypertens 29: 1802-1809, 2011

  15. Renal dysfunction is common in patients with T2DM Stage 3/5 NON albuminuric CKD phenotype 10.6% The RIACE Study: 15,773 patients with T2DM Albuminuria Normal Mild (micro) Severe (macro) Stage 0 (no CKD) 62.5% Stage 1 Stage 1-2 albuminuric phenotype 18.7% >90 Stage 2 60-89 eGFR ml/min/ 1.73m2 MDRD Stage 3 Stages 3/5 albuminuric CKD phenotype 8.2% 45-59 30-44 Stage 4 15-30 Penno G et al. J Hypertens 29: 1802-1809, 2011

  16. “Natural” history od Diabetic Retinopathy in type 1 and type 2 diabetes: new paradigms

  17. “Natural” history od Diabetic Retinopathy in type 1 and type 2 diabetes: new paradigms Normoalbuminuria Normal GFR Microalbuminuria Cardiovascular events, death Macroalbuminuria Reduced eGFR ESRD Natural history of diabetic nephropathy: “non-albuminuric” pathway Natural history of diabetic nephropathy: “albuminuric” pathway

  18. Key points Classification of chronic kidney disease (CKD) by eGFR and albuminuria Renal impairment is common. Every second/third patient in our clinic might have signs of renal impairment Albuminuria and eGFR: complementary measures of (diabetic) CKD

  19. Kidney Disease: Improving Global Outcomes (KDIGO) classification Low risk Moderate risk High risk Very high risk KDIGO, Kidney IntSuppl 3: 1-150, 2013

  20. Associations of Kidney Disease measures with mortality and ESRD in individuals with and without diabetes: a meta-analysis Data for 1,024,977 participants (128,505 with diabetes) from 30 general population and high-risk cardiovascular cohorts and 13 chronic kidney disease cohorts Fox CS et al.,Lancet380: 1662-1673, 2012

  21. Associations of Kidney Disease measures with mortality and ESRD in individuals with and without diabetes: a meta-analysis Data for 1,024,977 participants (128,505 with diabetes) from 30 general population and high-risk cardiovascular cohorts and 13 chronic kidney disease cohorts Fox CS et al.,Lancet380: 1662-1673, 2012

  22. Associations of Kidney Disease measures with mortality and ESRD in individuals with and without diabetes: a meta-analysis Data for 13 chronic kidney disease cohorts Fox CS et al.,Lancet380: 1662-1673, 2012

  23. Risk of coronary events in people with chronic kidney disease compared with those with diabetes:a population-level cohort study 1,268,029 participants; median follow-up of 48 months 1,268,029 participants; median follow-up of 48 months; the Alberta Kidney Disease Network 75,871 1,104,713 12,960 15,368 59,117 Tonelli M et al.,Lancet,published online, June 19, 2012 eGFR by the CKD-EPI equation

  24. Risk of coronary events in people with chronic kidney disease compared with those with diabetes:a population-level cohort study Tonelli M et al.,Lancet,published online, June 19, 2012

  25. UAEone value UAEtwo values Predictive performance for the mean of 3 UAE values Reference line The Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study 4,062 subjects with at least two UAE measurements • Intra-individual CV: • 32.5% (14.3-58.9) • Concordance rate between a single UAE and the geometric mean: • Two UAE: • normo: 94.6%; • micro: 83.5%; • macro: 91.1%; • micro/macro: 90.6%; • Three UAE: • normo: 94.6%; • micro: 84.2%; • macro: 86.8%; • micro/macro: 90.8%. Pugliese G et al., Nephrol Dial Transplant26: 3950-3954, 2011

  26. The Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study Summary of results and conclusions • A single UAE value, thought to be encumbered with high intra-individual variability, is an accurate predictor of the stage of nephropathy in subjects with type 2 diabetes. • Multiple UAE measurements may not be necessary for classification purposes in both clinical and epidemiological settings. Pugliese G et al., Nephrol Dial Transplant26: 3950-3954, 2011

  27. Kidney Disease: Improving Global Outcomes (KDIGO) classification KDIGO, Kidney IntSuppl 3: 1-150, 2013

  28. Kidney Disease: Improving Global Outcomes (KDIGO) classification KDIGO, Kidney IntSuppl 3: 1-150, 2013

  29. Kidney Disease: Improving Global Outcomes (KDIGO) classification KDIGO, Kidney IntSuppl 3: 1-150, 2013

  30. The Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study Prevalence of stages 3-5 CKD in type 2 diabetes MDRD Study: 2,959 (18.8%) CKD-EPI: 2,715 (17.2%) CKD-EPI CKD Stage MDRD Study CKD stage Total Soggetti riclassificati con la equazione CKD-EPI sopra sotto No CKD 1 2 3 4-5 No CKD 9,821 (62.3%) 234 (1.5%) 10,055 (63.8%) 1 977 (6.2%) 283 (1.8%) 1,260 (8.0%) 2 75 (0.5%) 1,591 (10.1%) 77 (0.5%) 1,743 (11.1%) 3 44 (0.3%) 23 (0.1%) 2,342 (14.8%) 2 (0.1%) 2,411 (15.3%) 4-5 48 (0.3%) 256 (1.6%) 304 (1.9%) Total 9,865 (62.5%) 1,052 (6.7%) 1,897 (12.0%) 2,701 (17.1%) 258 (1.7%) 15,773 (100.0%) Pugliese G et al., Atherosclerosis218: 194-199, 2011

  31. The Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study Prevalence of stages 3-5 CKD in type 2 diabetes MDRD Study: 2,959 (18.8%) CKD-EPI: 2,715 (17.2%) Pugliese G et al., Atherosclerosis218: 194-199, 2011

  32. The Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study Summary of results and conclusions • Estimating GFR in patients with type 2 diabetes using the CKD-EPI equation provides a better definition of the cardiovascular burden associated with CKD, in terms of CVD prevalence and CHD risk score. Pugliese G et al., Atherosclerosis218: 194-199, 2011

  33. Comparison of risk prediction using the CKD-EPI Equation and the MDRD Study Equation for Estimated Glomerular Filtration Rate Distribution of estimated GFR Data from 1.1 million adults from 25 general population cohorts, 7 high-risk cohorts (of vascular disease), and 13 CKD cohorts Matsushita K et al, JAMA 307: 1941-1951, 2012

  34. Comparison of risk prediction using the CKD-EPI Equation and the MDRD Study Equation for Estimated Glomerular Filtration Rate Reclassification across estimated GFR categories Matsushita K et al, JAMA 307: 1941-1951, 2012

  35. Comparison of risk prediction using the CKD-EPI Equation and the MDRD Study Equation for Estimated Glomerular Filtration Rate Net reclassification improvements for all-cause mortality, cardiovascular mortality, and ESRD Matsushita K et al, JAMA 307: 1941-1951, 2012

  36. Key points Classification of chronic kidney disease (CKD) by eGFR and albuminuria Renal impairment is common. Every second/third patient in our clinic might have signs of renal impairment. Albuminuria and eGFR: complementary measures of (diabetic) CKD Cystatin C

  37. Kidney Disease: Improving Global Outcomes (KDIGO) classification KDIGO, Kidney IntSuppl 3: 1-150, 2013

  38. Kidney Disease: Improving Global Outcomes (KDIGO) classification KDIGO, Kidney IntSuppl 3: 1-150, 2013

  39. Kidney Disease: Improving Global Outcomes (KDIGO) classification KDIGO, Kidney IntSuppl 3: 1-150, 2013

  40. http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

  41. ….. the combined equation improved the classification of measured GFR ….. and correctly reclassified 16.9% of those with an estimated GFR of 45 to 59 ml per minute per 1.73 m2 as having a GFR of 60 ml or higher per minute per 1.73 m2. Inker LA et al, N Engl J Med 367: 20-29, 2012

  42. Cystatin C and estimates of renal function: searching for a better measure of kidney function in diabetic patients Pucci L et al., Clin Chem 53: 480-488, 2007

  43. Shlipak MG et al, N Engl J Med 369: 932-943, 2013

  44. 10.0% 13.7% 9.7% Shlipak MG et al, N Engl J Med 369: 932-943, 2013

  45. 59 83 88 Shlipak MG et al, N Engl J Med 369: 932-943, 2013

  46. Shlipak MG et al, N Engl J Med 369: 932-943, 2013

  47. Shlipak MG et al, N Engl J Med 369: 932-943, 2013

  48. Key points Classification of chronic kidney disease (CKD) by eGFR and albuminuria Renal impairment is common. Every second/third patient in our clinic might have signs of renal impairment. Albuminuria and eGFR: complementary measures of (diabetic) CKD Cystatin C Measuring GFR

  49. Kidney Disease: Improving Global Outcomes (KDIGO) classification KDIGO, Kidney IntSuppl 3: 1-150, 2013

  50. Pucci L et al, Diabet Med 18: 116-120, 2001

More Related