Download Diabetes and the Kidney

Diabetes and the Kidney
Richard Kingston
Department of Renal Medicine
Kent and Canterbury Hospital
Renal Services in Kent and East Sussex
Guy’s
King’s
Brighton
http://www.britishrenal.org/CKD-Forum/Educational-Resources.aspx
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Diabetic Nephropathy – a Natural History
(type II)
•25% have microalbuminuria at time of diagnosis
•microalbuminuria develops in approximately 15% and proteinuria in 5%
within 5 years
•20% of microalbuminuric patients who survive for 10 years develop
proteinuria, 50% remain microalbuminuric, 30% revert to
normoalbuminuria
•Treated, proteinuric, hypertensive Type 2 diabetics lose glomerular
function at the rate of approximately 8 ml/min/year.
•Individuals who survive for 10 years from diagnosis have an 8% risk of
developing end stage renal failure.
Microalbuminuria
Proteinuria
Stroke
Amputation
MI
Blindness
Falling GFR
10-20 yrs
Dialysis
The more ignorant, reckless and thoughtless a doctor is, the higher his
reputation soars even amongst powerful princes.
http://cks.nice.org.uk/diabetes-type-2#!topicsummary
Assessment
• Renal function – Creatinine and eGFR
• Albuminuria – Albumin-Creatinine ratio
– Microalbuminuria
– Proteinuria
• Alternative diagnosis
Why is proteinuria a problem?
Assesment
• Renal function – Creatinine and eGFR
• Albuminuria – Albumin-Creatinine ratio
– Microalbuminuria
– Proteinuria
• Alternative diagnosis
Management
• Start ACE inhibitor
• Treat BP
• Control Blood Glucose
• Manage cardiovascular risk factors
– BP <130/80
– Statin
– Aspirin
Management
• Start ACE inhibitor
• Treat BP
• Control Blood Glucose
• Manage cardiovascular risk factors
– BP <130/80
– Statin
– Aspirin
RENAAL results - Primary components2
Doubling of serum creatinine
Risk reduction: 25%
p=0.006
% with event
30
P
20
L
10
0
0
P (+ CT) 762
L (+ CT) 751
12
24
Months
36
48
689
692
554
583
295
329
36
52
Mean BP and Rate of Decline in GFR in
Diabetics and Non-Diabetics
MAP (mmHg)
GFR (mL/min/year)
95
0
98
101
104
107
-2
110
113
116
119
r = 0.69; P < 0.05
-4
-6
Untreated
HTN
-8
-10
-12
130/85
-14
Bakris GL, et al. Am J Kidney Dis.
2000;36(3):646-661.
140/90
Management
• Start ACE inhibitor
• Treat BP
• Control Blood Glucose
• Manage cardiovascular risk factors
– BP <130/80
– Statin
– Aspirin
Impact of Blood Pressure Reduction
on Mortality in Diabetes
Trial
Conventional
care
Intensive
care
Risk
reduction
P-value
UKPDS
154/87
144/82
32%
0.019
HOT
144/85
140/81
66%
0.016
Mortality endpoints are:
UK Prospective Diabetes Study (UKPDS) – “diabetes related deaths”
Hypertension Optimal Treatment (HOT) Study – “cardiovascular deaths” in diabetics
Turner RC, et al. BMJ. 1998;317:703-713.
Hansson L, et al. Lancet. 1998;351:1755–1762.
Diabetes: Tight Glucose vs Tight BP
Control and CV Outcomes in UKPDS
% Reduction In Relative Risk
0
Stroke
Any Diabetic
Endpoint
DM
Deaths
Microvascular
Complications
5%
-10
10%
12%
-20
24%
*
-30
32%
*
-40
-50
32%
*P <0.05 compared to tight glucose control
44%
*
Tight Glucose Control
(Goal <6.0 mmol/l)
37%
*
Tight BP Control
(Average 144/82 mmHg)
Summary
•
•
•
•
Prevention
Treat early and treat well
It isn’t all about the Kidney
Diabetics on dialysis need on-going support