Continuing Education:

Renal and DiabetesAlisa McAleer, Dietetic Intern

December 15, 2014

Southern Regional Medical Center

Outline

• Chronic Kidney Disease and Diabetes

• Recommendations & guidelines: Glycemic Control and Protein

• For the practicing RDN

• Patient education and counseling

Chronic Kidney Disease (CKD)

• CKD definition: Abnormalities of kidney structure or function, present for

> 3 months, with implications for health

• The most common cause of kidney failure ???

• Latter stages of Chronic Kidney Disease (CKD)

• 35%- Adults with Diabetes

Diabetic Nephropathy

• Diabetic nephropathy (DN)

• Glomerular hypertrophy

• Transient hyperfiltration

• Proteinuria

• Renal fibrosis

• Decreased glomerular filtration rate (GFR)

• Prevalence

• African Americans, Asians, Native Americans

• Risk factors

• Poor glycemic control, hypertension, tobacco use, age of onset

Kidneyabc.com

Diabetic

Nephropathy

Albuminuria

Stages• Stage – A1

• <30 mg/24hrs (Normal)

• Stage – A2

• 30-300 mg/24hrs (Moderately increased albumin urinary excretion)

• Stage – A3

• >300 mg/24hrs (Severely increased albumin urinary excretion)

Screening

• Type 1 Diabetes

• 5 years after diagnosis

• Type 2 Diabetes

• Upon initial diagnoses

Renal & Diabetes

Current Regulations and Guidelines

Glycemic Control

• Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE)

• Subjects (randomized)

• Tight glycemic control (Hgb A1c <6.5%)

• Standard control

• 10% risk reduction in macro/microvascular events

• 21% reduction in nephropathy

• Meta-analysis published in 2012

• Tight glycemic control reduces overall albuminuria

• Target goal A1c <7%

Low Protein Diet

• Low-Protein and Diabetic

Nephropathy: Meta-analyses

• LPD – 0.6-0.8 g/kg/day

• Control – 1-1.6g/kg/day

• Actual Protein Intake Ratio (APIR)

• Protein intake

• Diet compliance

• Protective effects

• Improved eGFR & proteinuria

• No negative impact on glycemic

control

• Sustainable intervention is key!

CKD: Protein Intake for Diabetic

Nephropathy:

Academy Supported Evidence• WHAT ARE THE PROTEIN REQUIREMENTS TO MINIMIZE DISEASE

PROGRESSION WHILE MAINTAINING ADEQUATE NUTRITION STATUS IN ADULT NON-DIALYZED PATIENTS WITH DIABETIC NEPHROPATHY?

• CKD: Protein Intake for Diabetic Nephropathy

• For adults with diabetic nephropathy, the RD should recommend or prescribe a protein-controlled diet providing 0.8g to 0.9g of protein per kg of body weight per day. Providing dietary protein at a level of 0.7g per kg of body weight per day may result in hypoalbuminemia and potential risk of malnutrition. Research reports that protein-restricted diets improved microalbuminuria.

• American Diabetes Association: 0.8g/kg

Renal and Diabetes

The RDN

RDN Skill Level

• Competent, proficient and expert

• Certificate of Training Program in CKD Nutrition Management

• CDR’s Board Certification in Renal Nutrition

Diet Intervention

• Kidney disease

• Uremia

• Hypertension

• Edema

• Hyperkalemia

• Hyperlipidemia

• Blood glucose

Patient Education and Counseling

• Obesity

• Increased risk for DN

• Hyperlipidemia

• Coronary disease – lipid management

• Vitamin D therapy

• RAAS and albuminuria

• Antioxidants

• Not recommended as a treatment

Patient Education and Counseling

• Carbohydrate Counting

• Keep cholesterol level under control

• Limit protein to a healthy level based on individualized recommendations

(CAUTION)

• Limit sodium intake, <2 grams

Summary

• Early detection

• Proper screening

• Management

References

• Academy of Nutrition and Dietetics Evidence Analysis Library. (n.d.). CKD: protein intake for diabetic nephropathy. Retrieved December 7, 2014, from andeal.org: http://www.andeal.org/template.cfm?template=guide_summary&key=2409

• American Diabetes Association. (2014). Nephropathy in diabetics (Position statement). Diabetes Care, 37(12).

• Franz, M. J., Powers, M. A., Leontos, C., Holzmeister, Kulkarni, K., Monk, A., . . . Gradwell, E. (2010, December). The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. Journal of the American Dietetic Association, 110(12), 1852-1889. doi: http://dx.doi.org/10.1016/j.jada.2010.09.014

• Kent, P. S., McCarthy, M. P., Burrowes, McCann, L., Pavlinac, J., Goeddeke-Merickel, C. M., . . . Benner, D. (2014). Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 standards of practice and standards of professional performance for Registered Dietitian Nutritionists (competent, proficient and expert) in nephrology nutrition. Journal of the Academy of Nutrition and Dietetics, 1448-1503.

• Kowalski, A., Krikorian, A., & Lerma, E. V. (2014). Diabetic nephropathy for the primary care provider: new understandings on early detection and treatment. The Ochsner Journal, 14(3), 369-379.

• Lowth, M. (2013). Chronic kidney disease - an update. Practice Nurse, 43(1), 34-39.

• Mahan, K. E.-S. (2012). Krause's food and the nutrition care process. St. Louis, MO: Elsevier.

• Nezu, U., Kamiyama, H., Kondo, Y., Sakuma, M., Morimoto, T., & Ueda, S. (2013, April 25). Effect of low-protein diet on kidney function in diabetic nephropathy: meta-analysis of randomised controlled trials. BMJ Open. doi:10.1136/bmjopen-2013-002934

• Steves, P. (2013). Evaluation and managment of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Annals of Internal Medicine, 825-830.

• Supplement: summary of recommendation statements. (2013). Kidney International, 3, 5-14. doi:10.1038/kisup.2012.77