dr m sivalingam renal unit, lister hospital, stevenage
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Dr M SivalingamRenal Unit, Lister Hospital, Stevenage
Diabetes is the leading cause of ESRF
>40% new patients starting dialysis in USA
~30% of patients in Western Europe
Incident ESRD patients USRDS - 2009
USRDS - 2009
Months on DialysisMonths on Dialysis
909084847878727266666060545448484242363630302424181812126600
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P = 0.02P = 0.02n = 59n = 59
Non-diabeticsNon-diabetics
DiabeticsDiabetics
n = 231n = 231
Prognosis on Renal Replacement Prognosis on Renal Replacement TherapyTherapy
Incidence decreasing in Type 1 Diabetics
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Finne, P. et al. JAMA 2005;294:1782-1787.
Incidence Rate of End-stage Renal Disease According to Time Period of Diagnosis of Type 1 DiabetesFinnish Diabetes Register >20000 pts
1. NICE Management of type 2 diabetes: NICE 20082. NICE Management of CKD: NICE 2008
NICE Type 2 Diabetes Guidance
NICE Management of type 2 diabetes: NICE 2008
First-pass urine specimenOnce annuallyUACRRequest specimen if UTI prevents analysis
Measure serum creatinine (SeCr) and calculate eGFR (MDRD) annually at the time of ACR estimation
Repeat the test if abnormal ACR
Result of MAU confirmed if further abnormal specimen
Stage Description GFR
1 Kidney damage, N or GFR ≥90
2 Kidney damage, mild GFR 60-89
3A
3B
Moderate GFR
Moderate GFR
45-59
30-44
4 Severe GFR 15-29
5 Kidney failure <15 (or dialysis)
Stages of CKD
Glycaemic control Blood pressure management MAU/proteinuria Lipid management Lifestyle management Antiplatelet therapy
NICE Type 2 Diabetes Guidance
CKD 2 CKD 2+ CKD 3 CKD 4
N 14202 1741 11278 777
Male 43.8 56.5 37.8 35.9
Age (yrs) 61.4 ±14.1 60.8 ±14.9 71.6 ±11.9 73.6±13.6
Death (%) 10.2 19.5 24.3 45.7
RRT (%) 0.07 1.1 1.3 19.9
Keith et al Arch Intern Med 2004;164:659-663
Death far more common than RRT at all stages
ACE or ARB in normal doses Supra-maximal doses of ARB Combination therapy Direct Renin Inhibitors Aldosterone antagonists
269 patients
~ 50% diabetic
1gm proteinuria
Median SCr 150
Burgess et al, JASN 20: 893–900, 2009
Withdrawn due to hyperkalaemia in about 4%
What about combination therapy?
Patients at low risk of progressive CKD Mean eGFR 73.6 mls / min Mean ACR 0.81 mg/mmol No of patients needing chronic dialysis
very low in all arms Primary renal outcome driven by death
(80%)
Type 2 Diabetes with Nephropathy Olmesartan or Placebo with standard
therapy 577 patients, 72% received ACE Follow up 3 years Doubling of SCr, ESRD or death Preliminary results - WCN
599 patients
Aliskiren or placebo to Losartan
ACR decreased by 20%
Parving et al
Reduces proteinuria when used alone Additive effect of Spironolactone Blood pressure effect as well as ?anti
inflammatory effect
59 patients with DM
Already on ACE or ARB
Randomised to Spiro or placebo
5 – high K
ACR decreased by 40%
van den Meiracker et al
Diabetics receiving 80 mg/d lisinopril, and had a urine albumin-creatinine ratio (ACR) of 300 to placebo, losartan100 mg/d, or Spironolactone 25 mg/d for 48 wks
Greatest antiproteinuric effect with Spironolactone
Similar degrees of BP lowering in all groups
Significant incidence of asymptomatic hyperkalaemia (6.0) in about 50%
Mehdi et al, JASN 2009
1. Progressive stage 4 and 5 CKD (with or without diabetes)
2. Heavy proteinuria (ACR ≥70 mg/mmol, approximately equivalent to PCR ≥100 mg/mmol, or urinary protein excretion ≥1g/24 hours) unless known to be due to diabetes and already appropriately treated
3. Proteinuria (ACR ≥30 mg/mmol, approximately equivalent to PCR ≥50 mg/mmol, or urinary protein excretion ≥0.5 g/24 hours) together with haematuria
4. Rapidly declining eGFR (>5 ml/min/1.73 m2 in one year, or >10 ml/min/1.73 m2 within 5 years)
5. Hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs at therapeutic doses people with, or suspected of having rare or genetic causes of CKD
6. Suspected renal artery stenosis
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