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Diabetic Nephropathy. Lance Sloan, MD Stephen Fadem, MD. Objectives. Educate physicians and nurses on practical management tips for diabetes control. Identify goals for diabetes therapy in patients with CKD with emphasis on prevention and medication side effects.

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diabetic nephropathy

Diabetic Nephropathy

Lance Sloan, MD

Stephen Fadem, MD

objectives
Objectives
  • Educate physicians and nurses on practical management tips for diabetes control.
  • Identify goals for diabetes therapy in patients with CKD with emphasis on prevention and medication side effects
at the end of this online presentation you should
At the end of this online presentation you should
  • Understand the relationship between diabetes and kidney disease
  • Know the difference between type 1 and Type 2 diabetes
  • Be familiar with some of the clinical trials that have shaped our progress
  • List key management objectives for Diabetes as it relates to progressive CKD
  • Be familiar with therapy for diabetes
incidence esrd due to diabetes in network 14 is 206 million
Incidence ESRD due to Diabetes in Network 14 is 206/million

Each year in Texas 206/million patients start dialysis because of diabetic nephropathy.

Texas has the highest incidence in the nation. Source: USRDS

predicted and actual cost adjusted by diagnosis
Predicted and actual cost adjusted by diagnosis

Dialysis management of diabetic ESRD patients, particularly with heart failure

Source: USRDS

two types of diabetes
Two Types of Diabetes
  • Type 1 – onset in youth, destruction of beta cells and a requirement for insulin
  • Type 2 – onset as adult or young adult, related to insulin resistance. May be treated with lifestyle modification, oral medications, and later may require insulin
type 1 diabetes
Type 1 Diabetes
  • Insulin-dependent/Juvenile onset
  • 20 to 30% develop microalbuminuria after 15 years
    • Amin, R, Widmer, B, Dalton, N & Dunger, DB: Unchanged incidence of Microalbuminuria in Children with Type 1 Diabetes since 1986: A UK based inception cohort. Arch Dis Child:adc.2008.144337, 2009.
  • Of the ones who develop this less than half progress to diabetic nephropathy
  • Associated with microvascular disease – retina and kidney. The increased sugar is neurotoxic – hence neuropathy
  • 2.2 percent will develop ESRD in 20 years and 7.8 percent in 30 years
    • Finne P, Reunanen A, Stenman S, et al. Incidence of end-stage renal disease in patients with type 1 diabetes. JAMA 2005; 294: 1782-1787.
type 1 diabetes continued
Type 1 Diabetes (Continued)
  • The microalbuminuria can regress – and it is not always related to the use of ACE or ARB therapy
    • Perkins, BA, Ficociello, LH, Silva, KH, Finkelstein, DM, Warram, JH & Krolewski, AS: Regression of Microalbuminuria in Type 1 Diabetes. N Engl J Med, 348:2285-2293, 2003
  • The risk of developing kidney failure after 20 to 25 years in patients who have no proteinuria is low
  • Labile swings in blood sugar because of autonomic insufficiency
  • Always requires insulin
  • If diabetic nephropathy develops, the patient will develop insulin resistance – metabolic syndrome due to kidney disease. Atherosclerosis and hypertension are not primary but secondary events
type 2 diabetes
Type 2 Diabetes
  • Common in Hispanics, Native Americans and Pima Indians
  • Incidence of ESRD is lower, but the disease is more frequent – thus it is the most common cause of renal failure
  • United Kingdom Prospective Diabetes Study
    • UKPDS – large British study, (predominantly Caucasians)
    • Adler, AI, Stevens, RJ, Manley, SE, Bilous, RW, Cull, CA & Holman, RR: Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int, 63:225-32, 2003.
    • Incidence of microalbuminuria 25% but incidence of ESRD only 0.8%
    • Microlbuminuria patients spent an average of 11 years before progressing to overt proteinuria
    • Only 2.3% progress from macroalbuminuria to ESRD
type 2 diabetes continued
Type 2 Diabetes (Continued)
  • Disease progresses slowly over many years and is associated with proteinuria. The urine should show more than just red cells.
  • In the elderly, it is impossible to clinically distinguish the hypertensive and atherosclerotic effects from the diabetic effects without a kidney biopsy.
  • Not associated with labile blood sugar swings
  • Insulin resistance
incidence of type 2 diabetes
Incidence of Type 2 Diabetes
  • Doubled in past 20 years
  • Framingham Offspring Study
  • Related to Lifestyle Change and Obesity
  • BMI Increase confirmed by NHANES Dataset
    • Source: American Heart Association
  • Prevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007
    • Total: 23.6 million people
      • 7.8 percent of the population—have diabetes.
      • Diagnosed: 17.9 million people
      • Undiagnosed: 5.7 million people
    • Source: NIDDK
metabolic syndrome
Metabolic Syndrome
  • Characterized by insulin resistance – 50 to 75 million Americans
    • High blood pressure
    • High blood sugars
    • High levels of triglycerides
    • Low levels of HDL
    • Increased waist line
  • It is associated with
    • Diabetes, Hypertension, stroke, cardiovascular disease
  • Dominant Features
    • Obesity, lack of exercise
diet plays a major role
Diet Plays a Major Role
  • The Sugar Fix
    • High fructose corn syrup
      • Decreases the ATP in cells – this decreases cell respiration and causes hypoxia in cells
      • Releases cytokines that impair nitrous oxide synthesis
      • Releases uric acid which increases blood pressure
      • Causes leptin resistance (Leptin turns off the appetite) continue to be hungry
      • Supersized – HFCS is in many soft drinks and other products
      • Americans eat more sugar, now have an epidemic of obesity, the metabolic syndrome, heart disease and diabetes
management objectives
Management Objectives
  • Lifestyle
    • An aspirin a day
    • Smoking and Exercise
    • Weight/cholesterol
  • Blood Pressure
  • ACE and ARB
  • Vitamin D
  • Diabetes Control
lifestyle an aspirin a day smoking and exercise weight cholesterol
Lifestyle - An aspirin a day - Smoking and Exercise - Weight/cholesterol
  • Can be a rewarding way to keep diabetes under control.
  • Requires a lifelong strategy
  • Diet: Avoid fructose, excess salt, trans fats and excess carbohydrates
  • Two alcoholic beverages at most/day
  • 25% incident diabetics are smokers
    • Potentiates kidney disease
    • Increases inflammation
  • Gentle aerobic exercise
  • Aspirin a day to reduce cardiovascular risk
ace and arb
ACE and ARB

Blood Pressure Control

blood pressure goal in ckd 130 80
Blood pressure goal in CKD< 130/80
  • Any person with abnormal kidneys is at risk for heart disease
  • Most patients will require two or more medications to control their blood pressure
  • Lowering the systolic blood pressure to <130 mm Hg is usually associated with a reduction in diastolic blood pressure to <80 mm Hg

Adapted from American Journal of Kidney Diseases, Vol 43, No 5, Suppl Suppl 1 (May), 2004: pp S14-S15

effect of ace inhibitors on progression of ckd
Effect of ACE Inhibitorson Progression of CKD

Maschio. N Engl J Med. 1996;334:939.

slide26

Proteinuria is a powerful determinant of renal deterioration.

Source: The New England Journal of Medicine -- November 12, 1998 -- Vol. 339, No. 20 Mechanisms of Disease: Pathophysiology of Progressive Nephropathies Giuseppe Remuzzi, Tullio Bertani

collaborative study group reduction of proteinuria in type 1 dm with ace
Collaborative Study Group – Reduction of proteinuria in Type 1 DM with ACE

Placebo

Captopril

60

37%

40

22%

20%

Percent

20

7%

4%

0

-20

-40

-40%

-60

Changes in

proteinuria

Incidence of

ESRD

Incidence of

mortality

Lewis EJ, et al. N Engl J Med. 1993;329:1456-1462.

arbs in diabetes the renaal trial
ARBS in Diabetes – The RENAAL Trial
  • (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan)
    • Brenner. BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G,Snapinn SM, Zhang Z, Shahinfar S; RENAAL Study InvestigatorsEffects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001 Sep 20;345(12):861-9.
  • Randomized, double-blind, multicenter, placebo-controlled
  • Losartan Vs Placebo and conventional BP medications
  • 1513 patients
  • Outcome: Composite of doubling creatinine, ESRD, Death
  • Followup 3.4 years
  • RESULT: Reduced doubling of creatinine by 25% and ESRD by 28%
arbs in diabetes irma
ARBS in Diabetes - IRMA
  • IRMA (Irbesartan Microalbuminuria) study
    • Parving HH, Lehnert H, Bröchner-Mortensen J, Gomis R, Andersen S, Arner P;Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group.The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med. 2001 Sep 20;345(12):870-8
  • multicenter, randomized, double-blind, placebo-controlled trial, randomized
  • 590 patients with type 2 diabetic nephropathy (albuminuria)
  • Randomized to irbesartan, 150 mg, 300 mg (Avapro) or placebo
  • Blood pressure medications allowed
  • Endpoint was overt nephropathy – a urine albumin at least 30% greater than baseline
    • 10/194 (300 mg group) – reached endpoint
    • 19/195 (150 mg group) – reached endpoint
    • 30/201 (Placebo group) – reached endpoint
    • Blood pressure unchanged
arbs in diabetes idnt
ARBS in Diabetes IDNT
  • IDNT (Irbesartan Diabetic Nephropathy Trial)
    • Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, Ritz E, Atkins RC, Rohde R, Raz I; Collaborative Study Group. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001; 345:851-860.
  • Randomized, double-blind, placebo-controlled
  • 1715 patients to irbesartan,amlodipine or placebo
  • 2.6 years
  • BP therapy allowed (with exception on study drugs)
  • Result:
    • Lowered risk of developing ESRD by 23%
what slows progression
What slows progression?
  • Proven interventions
    • Control blood sugar in diabetics
    • Strict blood pressure control
    • Certain meds: ACES (Angiotensin-converting enzyme inhibition) and ARBS (angiotensin-2-receptor blockade)
  • Studied, but inconclusive
    • Dietary protein restriction
    • Lipid lowering therapy
    • Partial correction of anemia
    • Vitamin D administration
how are we doing
How are we doing?

Am J Kidney Dis. 2005 Dec;46(6):1080-7.

Elderly diabetic patients

Medical insurance claims

65 years and older

30,750 patients studied (58.7% also had high blood pressure and/or protein in the urine)

Of these only 50.7% (CI 50.0-51.4) received an ACE or ARB

accomplish trial
ACCOMPLISH TRIAL
  • Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension (ACCOMPLISH) trial
  • Has been stopped early – accomplished its goal
  • benazepril plus amlodipine better than benazepril plus hydrochlorothiazide
  • Study group – Hypertensives at risk secondary to previous events or diabetes
  • 11,464 patients
    • ≥ 55 years old
    • BP ≥ 160
    • 60.4% with diabetes
    • Obese
    • Cardiovascular, renal disease or target damage
  • 70% treated with two or more agents
  • Only 37.5% had blood pressure les than 140/90
  • Endpoints – cardiovascular morbidity MI, (stroke, unstable angina, bypass) or death
  • ACE/amlodipine Risk reduced by 20% compared with ACE/diuretic
    • SOURCE: Presented by KA Jamerson, American College of Cardiology, March 31, 2008
vitamin d
Vitamin D
  • Type 1 Diabetes in children might be prevented with vitamin D supplements and 5 – 10 minutes of noon sunlight
  • Epidemiology study
  • UCSD
    • SOURCE: University of California - San Diego. "Sun Exposure And Vitamin D Levels May Play Strong Role In Risk Of Type 1 Diabetes In Children." ScienceDaily 5 June 2008. 10 March 2009 <http://www.sciencedaily.com­ /releases/2008/06/080605073804.htm>.
diabetes control
Diabetes Control
  • Sulfonylureas
  • Biguanides
  • Thiazolidinediones “Glitazones”
  • Meglitinides
  • DPP-4 Inhibitors
  • Incretin Memetics
  • Insulin
sulfonyureas
SULFONYUREAS
  • First category of oral agents for diabetes – now in third generation
  • Mainly for type 2 diabetes – work on existing beta cells
  • Increase secretion of insulin by binding to potassium channels and opening calcium channels
  • Can cause hypoglycemia and weight gain
biguanides
BIGUANIDES
  • Metformin used in obese type 2 diabetics
  • Maximum reduction in HgbA1c after 6 months
  • Action lasts additional 9 months with thiazolidinedione
  • With sulfonureas HgbA1C tends to increase
  • Reduced cardiovascular risks
    • Pharmacotherapy. 2007 Aug;27(8):1102-10.Loss of glycemic control in patients with type 2 diabetes mellitus who werereceiving initial metformin, sulfonylurea, or thiazolidinedione monotherapy.Riedel AA, Heien H, Wogen J, Plauschinat CA.
rosiglitazone
ROSIGLITAZONE
  • Controversy regarding risk of causing MI
    • Odds ratio 1.43
  • ADOPT – increased fractures
  • Associated with macular edema
  • Stimulates the PPARγ receptor
  • Not to be used in heart failure
    • Nissen SE, Wolski K. Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes. N Engl J Med. 2007;356(24):2457-2471.
incretin mimetics
INCRETIN MIMETICS
  • Exenatide (Byetta)
  • From the saliva of the gila monster
  • Incretin – mimetic
    • Enhances beta cell insulin
    • Blocks glucagon
    • Delays gastric emptying
  • Injection sub cutaneously 30 to 60 minutes before first and last meal – adjunctive therapy
  • Side effects – Gastrointestinal symptoms
  • FDA warning – pancreatitis – may be fatal
when to start insulin
WHEN TO START INSULIN
  • Start with oral agents (metformin) and proceed to insulin if goal is not achieved
  • May be able to manage for up to 6 years
  • HgbA1C – use a target
  • In kidney patients and those who may be operating heavy machinery – because of the risk of hypoglycemia – may want to have a higher goal
  • Mono-duo-triple therapy – disease has advanced
hgba1c
HgbA1C
  • American Diabetic Association 7.0%
  • American Society of Clinical Endocrinologist 6.5%
  • Many local endocrinologist 6.0%
  • CONTROVERSY: The lower the HgbA1C the lower the risk of microvascular disease, but the higher the risk of hypoglycemia
slide47

INSULIN

Adapted from Hirsch IB, Edelman SV Practical Management of Type 1 Diabetes, PCI Book,, West Islip Ny (2005)

insulin
INSULIN
  • Glucose homeostasis declines –
    • Loss of post prandial glycemic control
    • Decline in control around breakfast
    • Nocturnal Hyperglycemia
  • Consider prandial insulin before starting basal insulin
  • Basal insulin typically started in type 2
diabetes and the eye
Diabetes and the eye
  • Type 1
    • Almost always have retinopathy and neuropathy by the time they develop nephropathy, but many patients with retinopathy do not have nephropathy
    • Detected clinically by the doctor or opthalmologist
  • Type 2
    • Retinopathy will likely be accompanied by nephropathy
    • If no retinopathy is present, they may have something other than diabetic nephropathy
adopt a diabetes outcome progression trial
ADOPTA Diabetes Outcome Progression Trial
  • 4360 Patients with type 2 diabetes
  • Rosiglitazone, metformin, glyburide
  • Double blind randomized
  • Treated 4 years
  • Outcome – time to medial failure
  • Results
    • Monotherapy at five years – when compared with metformin
    • 32% risk reduction with rosiglitazone
    • 63% risk reduction with glyburide
    • Better blood sugar control with glitazone
  • N Engl J Med. 2006 Dec 7;355(23):2427-43. Epub 2006 Dec 4..Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy.Kahn SE, Haffner SM, Heise MA, Herman WH, Holman RR, Jones NP, Kravitz BG, LachinJM, O'Neill MC, Zinman B, Viberti G; ADOPT Study Group.
dream
DREAM
  • Lancet. 2006 Sep 23;368(9541):1096-105.
  • Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomised controlled trial.
  • DREAM (Diabetes REduction Assessment with ramipril and rosiglitazone Medication) Trial Investigators, Gerstein HC, Yusuf S, Bosch J, Pogue J, Sheridan P, Dinccag N, Hanefeld M, Hoogwerf B, Laakso M, Mohan V, Shaw J, Zinman B, Holman RR.
  • Multicenter – RCT – Rosiglitazone v placebo – follow up median of 3 years
  • Primary Outcome – Composite – incident diabetes or death
  • Type Intent to treat
  • GOAL: prevent type 2 diabetes in high risk patients
  • 5269 adults ≥ 30 years old with abnormal glucose tolerance, no prior CV diease
  • Composite reached
    • Rosiglitazone 11.6%
    • Placebo 26%
  • Euglycemic
    • Rosiglitazone 50.5%
    • Placebo 30.3%
    • Cardiovascular
  • Heart Failure
    • Rosiglitazone 0.5%
    • Placebo 0.1%
common medications to avoid in ckd
Common Medications to avoid in CKD
  • NSIADS
    • Ibuprofen (Motrin)
    • Indomethacin (Indocin)
    • Naproxen (Aleve, Anaprox, Naprosyn)
    • (Celecoxib) Celebrex
    • (Rofecoxib) Vioxx
  • METFORMIN
    • Glucophage, Diaformin
drugs that raise potassium
DRUGS THAT RAISE POTASSIUM
  • Beta blockers like propanolol
  • ACES
  • ARBS
  • Renin inhibitors
  • NSAIDS
  • Potassium sparing diuretics
lowering potasium
Lowering Potasium
  • Glucose and insulin
  • Albuterol
  • Kayexalate
  • Loop diuretics
  • Thiazide diuretics
hardening of the arteries
Hardening of the Arteries
  • Vascular Calcification
    • Potentiated by metabolic syndrome and kidney disease
    • Accumulation of phosphorus with decreased bone turnover in CKD associated with the metabolic syndrome potentiates changes in cells inside blood vessel walls
    • These vessels accumulate phosphorus and calcium – leading to vascular calcification
    • Common in diabetes and in CKD
diabetes complications
Diabetes Complications
  • Vascular Disease
    • Peripheral vascular disease
    • Amputations
  • Autonomic insufficiency
    • Gastroparesis
    • Postural hypotension
    • Bladder dysfunction
  • Neuropathy
    • Charcot Joints
    • Burning Neuropathy
impact of diabetes on dialysis blood pressure management
Impact of diabetes on dialysis blood pressure management
  • Autonomic insufficiency
    • BP drops and very labile
  • Medial Calcification
    • Wide Pulse Pressure
  • Hypertensive cardiomyopathy
    • Preload
    • Cardiac function
    • Afterload
summary of prevention
Summary of prevention
  • Lifestyle Modification
  • ACE inhibitor therapy
  • ARB therapy
  • Control Blood sugar
  • Control Blood pressure
  • Vitamin D
  • Titrate proteinuria