Diabetes and Proteinuria Dr Ruba Nashawati Diabetes q
Diabetes and Proteinuria Dr. Ruba Nashawati
Diabetes q Leading cause of ESRD q 30% 40% � DN q DN Risk type I = type II
Familial Cluster Type I 83% 1 st degree relative Type II 74% 1 st degree relative
Renal Injury Hemodynamic Hyperperfusion Glucose balance Hyperproliferation 4
Diabetic Nephropathy 5
Clinical syndrome Persistent Albuminuria >300 mg/24 hr � GFR � HTN Cardiovascular Morbidity And Mortality
Proteinuria 8
Glomerular Barrier tubule q Normally, the larger Proteins are excluded at the glomerular barrier q Smaller proteins can pass, but are mostly Reabsorbed 9
Leaky Glomerular Barrier tubule Large Proteins are able to pass by the abnormal glomerular barrier 10
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PLASMA PROTEINS EXCRETION (mg/day) Plasma proteins Nonplasma Proteins Albumin 12 Tamm-Horsfall protein 40 Immunoglobulin G 3 Other non–renal <1 Immunoglobulin A 1 All Nonplasma proteins 40 Immunoglobulin M 0. 3 Light chains χ 2. 3 λ 1. 4 β-Microglobulins 0. 12 Other plasma proteins 20 All plasma proteins 40 Total Proteins 80 ± 24 12
� Systemic Hypertension Hyperperfusion � Capillary Pressure � Glomerular Hydrostatic Pressure Proteinuria 13
Renin-Angiotensin-Aldosterone System Sites of action: 1. Podocytes 2. Mesangial cell 3. Endothelial cell 4. Renal vessels 5. Tubular cell
Renin-Angiotensin-Aldosterone System Hemodynamic Nonhemodynamic (Mediates Cell) 1. Proliferation 2. Hypertrophy 3. Matrix Expansion 4. Cytokine(TGF-β)synthesis
Diagnosis 17
Edema often 1 st symptom DN 18
Urine Dipstick Only Albumin � Insensitive in Microalbuminuria � 19
Spot Urine Albumin/Creatinine Ratio Easy � Yearly � Control DM patient � 20
Gold standard 21
Albuminuria 22
Microalbuminuria �� Albumin excretion (30 to 300 mg/day) � persists over 3 -6 month � 24
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Clinical Evaluation Of Diabetic Nephropathy 26
Treatment Of Diabetics With Microalbuminuria Or Overt Nephropathy 29
Goal Reduce Progression of Nephropathy + Minimize the risk for CV events the rate of
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Diabetic Nephropathy
corrected Good Glycemic Control ACEi
Anti Hypertensive Agents 34
ACEi /ARBs Hypertensive + Diabetic Normotensive + Nondiabetic + Ratio>30 mg/g 35
ACEi /ARBs v Don’t prevent Proteinuria v Reverse the progression of Proteinuria 60% 36
ACEi /ARBs v Stop �Cr >30% �K AKI v CKD = not contraindication 37
ACEi /ARBs Check Creatinine day 3 week 2 38
Diuretics Loop diuretics Thiazide Aldosterone Antagonist 39
Calcium Channel Blocker Only Nonhydropyridin CCB (Diltiazem , Verapamil) Are Anti Proteinuric 40
B-Blocker 41
Direct Renin Blocker Aliskiren 42
Glycemic Control 44
Strict DM+DN � HBA 1 c 7. 0% Type I Evidence Based 45
More aggressive in 1. Young 2. Short DM Duration 3. High Life Quality 4. Risk Of Hypoglycemia 46
Treatment Of Dyslipidemia 47
1. Usually �HDL + �Tg 2. Type II +Non-Dialitic �statine 3. ESRD �too late 48
Goal 1. 2. DM �LDL <100 mg/dl DM +CVD �<70 mg/dl 49
Non Pharmacologic 50
� Low Protein Diet 0. 8 g/Kg/Day � K + Na Restriction � Life Style Modification 51
Other New 52
� Peroxisome Proliferation Activated Receptors � Thiazolidinedione (Pioglitazone) +ARBs � MMF � Fish Oil 53
Take Home Messages 54
Proteinuria � Early discover � DM control � ARBs /ACEi as Detected 55
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