Chronic Kidney Disease (CKD) and Diabetes Treatment

Chronic Kidney Disease Chronic Kidney Disease (CKD) and Diabetes(CKD) and Diabetes

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Medic Yatra Kidney FoundationMedic Yatra Kidney Foundation




Current Terminology

• Kidney, not Renal (or Reno)

• CKD, not CRF

• DKD (= diabetic nephropathy)

• AKI, not ARF

• Still ESRD (End Stage Renal Disease)

• Still RRT (Renal Replacement Therapy)




ESRD Incidence Counts and Ratesby Primary Diagnosis (USRDS, 2006)

Better CKD Management?




Glomerulus = filtering unit







Importance of Diabetic Kidney Disease

• Kidney disease as diabetic complication:– 30% of Type 1 Diabetes– 40% of Type 2 Diabetes

• CKD amplifies CVD risk of diabetes




Diabetic Kidney Disease Screening• WHEN

– Type 1: after 5 years, then annually– Type 2: at diagnosis, then annually

• HOW– Albumin-to-Creatinine ratio in random urine

• Microalbuminuria = 30-300 mg/g• Macroproteinuria

– Estimate GFR (eGFR) from serum creatinine using formulas

– Retinopathy: useful clue




Stages of CKDStage ICD-9 GFR

(mL/min/1.73M2)

1 585.1 > 91 + damage

2 585.2 60-89 + damage

3 585.3 30-59

4 585.4 15-29

5 585.5 < 15

6 585.6 ESRD on RRT
















Action Plan in the Clinic• Determine AKI vs. CKD?• Estimate GFR and rate of decline• Identify kidney disease requiring specific Rx• Slow progression of CKD• Review medications• Identify + treat systemic complications• Prepare for replacement therapy

Depending on CKD Stage




Formulas for Estimating GFR• Cockcroft-Gault• MDRD (Modification of Diet in Renal Disease Study)

– GFR calculator (www.kidney.org)

• GFR depends on:– Serum creatinine– Age– Gender– Race



http://www.kidney.org/


Interventions to Slow CKD Progression

• Strong evidence– Blood pressure control– ACEI / ARB– Glucose control in DM

• Weaker evidence– Protein restriction– Lowering LDL cholesterol
















Management of Albuminuria in Normotensive Diabetic

• Normotensive DM patients with macroalbuminuria should be treated with ACEI / ARB

• Treatment with an ACE inhibitor or an ARB should be considered in normotensive persons with diabetes and microalbuminuria






AKI Superimposed on CKD• Dehydration

• BP too low

• Obstruction

• Contract dye

• Drugs– Nephrotoxic or allergic or hemodynamic– NSAID (including Cox-2 inhibitors)– ACEI / ARB



Systemic Complications of CKD

• Hypertension

• Cardiovascular disease

• Anemia

• Calcium-phosphorus-parathyroid



American Heart Association

• Patients with CKD– Should be considered as highest-risk group

for CVD– Should be treated as such

Sarnak, Circ, 2004



Left Ventricular Hypertrophy in CKD

Risk factors: HTN and AnemiaLevin, AJKD. 1999; Foley, KI, 1995



Erythropoietin Stimulating Agent in CKD

• Administration (SQ q 1-4 wk)– Epoietin-α (start 75-150 units/kg)– Darbepoetin (start 0.45 μg/kg)

• Target Hgb (11-12 g/dL)

• Adverse effects– Iron deficiency (may need IV iron)– Hypertension







What is Renal Diet?

• Low sodium

• Low potassium– What about DASH?

• Low phosphorus– Adding glucose and fat targets?

• Should be individualized





Symptoms of Uremia

• None or subtle

• Fatigue, lack of energy

• Anorexia (nausea/vomiting)

• Sleep disturbance

• Impaired cognitive function

• Impotence



When to Start Replacement Therapy• Phophorus higher than hct• Pale and sallow• Needs a razor blade to scratch the itch• Vomiting day & night• Legs twitching• Hands flapping• Uremic smell you cannot stand

• Too late!!• Should start no later than mildly symptomatic• Usually GFR 7-8 mL/min



Preparation for RRT

• GFR 20 mL/min (depends on rate of decline)

• Early CKD education (including diet)

• Early nephrology referral for co-management (delineate responsibilities)

• Arm vein preservation





Chronic Kidney Disease (CKD) and Diabetes Treatment

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