DIABETIC NEPHROPATHYPAA KWESI HACKMAN

RD, LD, MSC DIETETICS, BSC NUTRITION AND FOOD SCIENCE

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OutlineDEFINITIONEPIDEMIOLOGYRISK FACTORSPATHOPHYSIOLOGYSIGNS & SYMPTOMSCOMPLICATIONSMEDICAL DxMANAGEMENTMNTCONCLUSION

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DefinitionIt is a clinical syndrome characterized

by:• Persistent albuminuria (>300 mg/d or >200

μg/min) confirmed on at least 2 occasions 3-6 months apart.

• Progressive decline in GFR. • Elevated BP.

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Epidemiology382m (8.3%) adults with DM by 2013.

592m projected by 2035.Global mortality – 6%.

Almost a third of people with DM develop DN

DN 35-40% T1DM Pts. 15-20% T2DM Pts.Leading cause of ESRD. (6th IDF Atlas, 2013; ADA, 2007)

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Risk Factors

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Pathophysiology /I

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Pathophysiology /II

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S/SOedemaTroubled sleep or concentrationPoor appetiteNauseaWeakness Itching and extremely dry skinArrhythmia Muscle twitching

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ComplicationsHTNAnaemiaBone abnormalitiesCVDMalnutritionMetabolic acidosisUremiaHyperlipidaemia

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Medical Dx Blood tests

Urine tests• Dipstick• Alb:Cr ratio > 2.5 in males and > 3.5 in females is

abnormal.• Confirmed with AER of 20-200ug/min or 30-

300mg/24hrs & eGFR.

Imaging tests

Kidney biopsy (ADA, 2004) 10

Management

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MNT12

MNT Goals Achieve and maintain:

• BGL in the normal or safe.• Lipid profile that reduces CVD risk.• BP normal or safe.

To maintain good nutritional status, slow progression, and to treat complications.

To achieve weight loss in overweight or obese states.

To Enhance health through food choices and physical activity.

(ADA, 2008)

(ADA, 2008)

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MNT: Nutrition Assessment Anthro’s Biochemical Client Hx Diet Hx Nutrition-focused Physical findings

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MNT: Nutrition Dx /I

Inadequate energy intake Inappropriate intake of types of CHO Inadequate fibre intake Excessive mineral intake (Na+ or K+) Altered GI function (gastroparesis) Altered nutrition-related Lab values Food-medication interaction

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MNT: Nutrition Dx /IIFood-medication Interaction Underweight Food- and Nutrition-related Knowledge Deficit Not Ready For Diet/Lifestyle ChangeSelf-monitoring DeficitUndesirable Food ChoicesPhysical InactivityInability or Lack of Desire to Manage Self-care

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MNT: Intervention /I Nutritional education

Modified DASH Diet employed

Rx: CHO: 50-60% Protein: 10-20% Fat: < 30% (<10% Sats) Protein: 0.8 - 1g; 0.8g (in ESRD) & 1.2g/kg/d (dialysis)

Sodium: max = 2g/d

(NKF KDOQI, 2007; ADA, 2008)17

MNT: Intervention /II To limit K+-rich foods in hyperkalemia

Fluid: 600-1000ml (severe oedema & dialysis)

Micronutrient supplementation may be necessary

Adequate PAL as tolerated

(NKF KDOQI, 2007; ADA, 2008)18

MNT: M & E Weight

Intake

Labs

BP

Nutrition-focused physical findings

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Conclusion DN develops over a long duration. Timely screening is paramount. Aggressive mgt. of BGL, BP & Lipids helps in

preservation of renal function and can improve the outcome.

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References KDOQI Clinical Practice Guidelines and Clinical Practice

Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis. 2007;49(2 suppl 2):S12-S154.)

American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004

American Diabetes Association Standards of medical care in diabetes. Diabetes Care 30:S4-S36, 2007

American Diabetes Association Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

Hansen HP, Tauber-Lassen E, Jensen BR, et al. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney Int.2002;62(1):220-228.

IDF Atlas (2013). Pedrini MT, Levey AS, Lau J, et al. The effect of dietary protein

restriction on the progression of diabetic and nondiabetic renal diseases: meta-analysis. Ann Intern Med. 1996;124:627-632.

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•THANK YOU

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