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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