Download Diabetes and the Renal Patient

Diabetes and the Renal
Patient
Objectives
• Review and discuss functions of the Kidney
• Identify challenges related to caring for people with
Diabetic/End-Stage Kidney Disease
• Review updated KDOQI clinical practice guidelines
for Diabetes and CKD
• Review and discuss dietary guidelines for caregivers
in the treatment of DKD.
•.
ESRD Incidence by Diagnosis
ESRD and DM
KDOQI Clinical Practice Guidelines
• Guideline 1: Screening and Diagnosis of Diabetic
Kidney Disease
• Guideline 2: Management of Hyperglycemia and
General
• Diabetes Care in Chronic Kidney Disease
• Guideline 3: Management of Albuminuria in
normotensive patients with Diabetes
• Guideline 4: Management of Dyslipidemia in
diabetes and Chronic Kidney Disease
• Guideline 5: Nutritional Management in Diabetes
and Chronic Kidney Disease
Source: Am
J Kidney Dis. 2012;60(5):850-886
Stages of Chronic Kidney Disease
Challenges: Renal Hypoglycemia
Glycemic Control in Dialysis
• A1c can be affected by:
• High BUN
• Iron deficiency
• Hemolysis
• Shorter life of red blood cells
• Acidosis
• Use of EPO
• BEST ASSESSED BY USING A COMBO OF A1C AND SMBG
Hypoglycemia Treatment
• Encourage diabetic patients to eat pre/post
treatment. Consider Eating at Treatment
“policy”.
• Treat if symptomatic at glucose of 80-90
• Encourage glucose tablets or gels
• DO NOT treat with OJ or Nepro
KDOQI CPG FOR DIABETES AND CKD –
Hyperglycemia/general care
Recommend:
• HbA1c of ~ 7.0% to prevent or delay progression of the microvascular complications of diabetes, including DKD. (1A)
• Do NOT treat to an HbA1c target of < 7.0% in patients at risk of
hypoglycemia (1B)
Suggest:
• that target Hba1c be extended above 7.0% with co-morbidities, risk
of hypoglycemia or limited life expectancy (2C)
Challenges: CVD in CKD
Traditional risk factors
• Hypertension
• Diabetes
• Dyslipidemia
• Smoking
• Age
• Inflammation
Nontraditional risk factors
• Albuminuria
• Anemia
• Abnormal metabolism of calcium
and phosphorus
KDOQI -CPG FOR DIABETES AND CKD –
Dyslipidemia
• Recommend using LDL-C lowering medicines, such as statins or
statin/ezetimibe combination, to reduce risk of major
atherosclerotic events in patients with diabetes and CKD,
including those who have received a kidney transplant.
• Recommend NOT initiating therapy in patients with diabetes
who are treated by dialysis.
ESRD & DM: Fistula Patency
•Diabetes is an independent risk
factor for loss of AV fistular patency
after 6 months of use
•Diabetes is associated with CVC
failure
ESRD & DM - Infections
• Generalized infection is the second leading cause of death in
dialysis patients.
• More common in diabetics (2.7% vs 1.7% compared with non DM)
• Septicemia and CVC catheter-related infections higher in diabetic
patients
Challenges: ESRD & Retinopathy
• High prevalence in new dialysis patients
• Up to 73% show visual disturbance
Challenge: Gastrointestinal Autonomic
Neuropathy
• Gastroparesis – 50% occurrence
• GERD: 30% occurrence
• Diabetic diarrhea: 20% occurrence
• Fecal incontinence
• Constipation
• All impact patient’s diets!!
Challenge: Higher incidence of LEA with
ESRD due to DM
• 85% of LEA due to diabetic neuropathy associated with foot ulcers
• Low kt/v (adequacy marker) = strong risk for LEA as uremia
predisposes infection and PAD
• Encourage Daily Foot Checks!!
PD in DM management
• High concentrations of glucose can lead to hyperglycemia
• Glucose is higher in diabetics with high peritioneal transport
states
• Poor glycemic control = increased thirst = need for higher
glucose concentrations = higher glucose levels
NODAT – New Onset Diabetes After
Transplant
NODAT – New Onset Diabetes After
Transplant
KDOQI: Nutritional Management in Diabetes
and CKD
• Nutritional Management in Diabetes and CKD Management of
diabetes and CKD should include nutritional intervention. Dietary
modifications may reduce the progression of CKD.
• Target dietary protein intake for people with diabetes and CKD stages
1-4 should be the recommended daily allowance (RDA) of 0.8 g/kg
body weight per day.
KDOQI – Nutritional Management in Diabetes
and CKD
• The care of people with diabetes and CKD should incorporate a
multifaceted approach to intervention that includes instruction in
healthy behaviors and treatments to reduce risk factors.
• Target body mass index (BMI) for people with diabetes and CKD
should be within the normal range (18.5-24.9 kg/m2 ).
Nutrition Therapy – Talking points
• Carbs still count!!
• Choose low potassium juice to treat hypolycemia
• Choose and fix foods with less salt and sodium
• Eat the right amount and types of protein
• Choose foods with less phosphorus
• Limit dietary potassium when serum levels are elevated
Medical Nutrition Therapy
NUTRIENT
INTAKE
EVALUATING TOOLS
Protein
CKD –HD 1.2 -1.3 gms/kg
CKD 3-5 - 0.6-0.8 gms/kg
PD – 1.2 -1.3 gms/kg
50% HBV
Serum Albumin
nPCR
Dietary recall
Energy
30-35 cal/kg BW
PD – include calories from dialysate
BMI
%SBW
SGA rating
Adjust for age, acuity, activity and weight goal
Phosphorus
800-1000 mg/day
Restrict when serum PO4 and PTH levels are ^
Serum phosphorus
Calcium
PTH
Calcium
2000 mg/maximum/day
Serum calcium (corrected for low
albumin)
Potassium
~ 2000 mg/day; otherwise unrestricted unless serum levels are
elevated
Serum potassium; clinical signs and
symptoms
Sodium
1000-3000 mg/day
Serum sodium; edema, weight history
Fluid
CKD –HD – 32 oz/day + urine output
PD – 1500- 2000
CKD 3-5 – Unrestricted unless otherwise indicated
Weight history; dietary recall for Na
intake; medications.
FOODS
Stages 3-4 CKD
Stage 5
ESRD
Non/low fat dairy
Limit to ½ cup per day or
amount decided by RD
Limit to ½ cup per day or amount decided
by RD
Animal Protein
sources
Include; avoid excess: 0.6
gms/kg BW
All types of dialysis: INCREASE - .8 -1.2
gms/kg BW
Grains, pasta and rice Include
(whole and other
grains
All types of dialysis: Include; BUT make
lower phos. whole grain choices
Fruits and vegetables Include
ICHD: lower K+ choices/limit portions
PD/HHD: possible K+ supplement
Legumes (beans,
lentils, peas)
Servings depend on K+ and PO4 Servings depend on K+ and PO4 blood test
blood test results
results
Seeds and Nuts
Servings depend on K+ and PO4 VERY limited; avoid if K+ and PO4 are high.
blood test results
FOODS
STAGES 3-4 CKD
STAGE 5
ESRD
Sat./trans Fats
Limit or avoid
CKD 1-4
Limit or avoid
Fats: monos/polys
Include
Include
Sweets/sugary foods and drinks
Limit
Limit
Salt, soy sauce, salty seasonings Limit or avoid
CKD 1-4
Limit or avoid
Phosphate Additives
Avoid
CKD 1-4
Avoid
Herbs and spices
Include
Include
What About Low-Protein Diets?
LPD’s = 0.6g/kg/day
• Traditional – mixed proteins that work with quantity and
quality of food
• Vegan – integrates grains and legumes – requires
supplementation
vLPD’s = 0.3g/kg/day
• Combines both approaches
• Requires higher doses of supplements
Diabetes and Dialysis -Plate
Carlos Mendes
• Background: Mr. Mendes is a 77 year old Hispanic man with Type 2
diabetes since 1999. He is here to learn how to treat hypoglycemia in
CKD. For the past 2 months, he needed to drink 10 oz. of orange juice
almost every night to treat low glucose levels.
• He started drinking regular cola with his meals in place of his usual
diet cola to keep his blood glucose up during the day as well. His wife
does not add salt to cooking.
Carlos Mendes
• Meds: Enalapril 10 mg. daily, lovastatin 40 gm daily,
baby aspirin daily, renal vitamin, ergocalciferol
50,000IU weekly.
• NEW: furosemide 80 mg daily
• D/c’d Glipizide Xl 10 mg.
Measure
3/9/12
12/13/11
9/27/11
Weight
197
203
200
Blood
Pressure
139/82
146/96
140/90
Carlos Mendes
1 cup refried
2 fast food beef
beans
tacos
3 corn tortillas
20 oz. regular cola
16 oz. brewed
coffee/1oz canned
milk
Snack: Apple
1 cup fideos
(pasta) fried in 1
tsp. oil
3 oz. fried beef
with onions in 1
Tbsp. oil
½ c. refried beans
(lard)
12 oz. regular cola
Carlos Mendes
Measure
Glucose
Hgba1c
3/9/12
76
6.6
12/13/11
298H
11.4
9/27/11
197H
10.9
BUN
Creatinine
eGFR
Potassium
43H
3.1H
20
5.3H
28H
2.6H
24
4.4
22H
2.5H
25
4.5
CO2
Calcium
20.2L
8.4L
27.2
8.2L
24
8.2L
Phosphorus
4.3
3.4
3.5
Albumin
Cholesterol
2.5L
184
2.7L
---
2.8L
203
LDL
Hemoglobin
104H
12.4
-----
136
13.6