Diabetic Nephropathy

Transkript

1 Diabetic Nephropathy

2 Steno Diabetes Center

3 The magnitude of the problem Total number of people with diabetes (age 20-79) Prevalence of diabetes (age 20-79) 285 million 438 million 6.6 % 7.8 %

4 Diabetes Mellitus 2010 Skøn over udbredelse i Danmark Type 1 Type 2 Insulin behandlet Type 2 Diæt/tbl. behandlet Type 2 Ikke diagnosticeret

5 Critically important to protect this woman David Savage, Belfast

6 Diabetisk nefropati overblik.. Mikro-albuminuri a call for action Hvilke undersøgelser hvornår? Hvilken behandling? Kliniske udfordringer Leucopatch..

7 Urinary albumin excretion rate normo micro macro < 30 mg/24h mg/24h > 300 mg/24h

8 Albuminuria (µg/min) Progression of Diabetic Renal Disease in Patients with Diabetes 2000 Overt nephropathy 40% Microalbuminuria Normoalbuminuria Time (Years) 60%

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12 U alb/cr (mg/g) Urinary albumin / creatinine (mg/g) day-to day variation Follow-up (days)

13 2 min? Taler I med patienterne om nyresygdom? Hvad spørger I dem om?

14 Microalbuminuria is NOT only a test result, but a call for ACTION! 14 PHG, MS

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16 Prevalence of late complications in 549 NIDDM patients aged < 76 years attending Hvidöre Hospital Normo- Micro- Macro- albuminuria Albuminuria Hypertension Retinopathy

17 Diabetic Maculopathy

18 Central vision loss

19 Prevalence of late complications in 549 NIDDM patients aged < 76 years attending Hvidöre Hospital Normo- Micro- Macro- albuminuria Albuminuria Hypertension Retinopathy CHD

20 Proteinuria Predicts Stroke and CHD Events in Type 2 Diabetes 1 Survival curves for CVD mortality 40 Incidence of CVD (%) A B p< Overall: p<0.001 C Stroke CHD Months events A: U-Prot <150 mg/l B: U-Prot mg/l C: U-Prot >300 mg/l Miettinen H et al. Stroke. 1996;27:

21 Hjertekar sygdom findes ikke kun ét sted i kroppen

22 Prevalence of late complications in 549 NIDDM patients aged < 76 years attending Hvidöre Hospital Normo- Micro- Macro- albuminuria Albuminuria Hypertension Retinopathy CHD Foot ulcers Neuropathy

23 Diabetisk neuropati - symptomer Somatisk neuropati Autonom neuropati Smerte Hyperfølsomhed Nedsat følesans Føleforstyrrelser Kramper Muskelsvækkelse Svimmelhed Gastroparese Diarre / Forstoppelse Blære forstyrrelser Abnorm sved tendens Impotens Pulsændringer Manglende føling ved lavt BS

24 The kidney

25 Glomerulus = the filtration unit

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27 Normal glomerulus

28 Diabetic nephropathy

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30 Måling af nyrefunktion = GFR

31 Glomerular filtration rate (ml/min/1.73 m 2 ) Progression of renal failure i 9 diabetic patients End stage renal disease Jones et al, The Lancet 1979

32 Hæmodialyse

33 35 In c id e n c e o f d ia b e tic p a tie n ts s ta r tin g re n a l re p la c e m e n t th e r a p y fro m (p m p ) 30 Danish Kidney Database 25 T y p e 1 a n d T y p e T y p e 1 5 T y p e

34 behandling?

35 Cardiovascular disease in diabetic nephropathy BP reduction (< 120/80) Diuretics Stop smoking ASA 75 mg x 1 Statins

36 Effective long-term antihypertensive treatment in diabetic nephropathy Reduces albuminuria Reduces the rate of decline in kidney function Postpones end stage renal disease Improves survival

37 Cumulative mortality (%) Mortality Knowles 1971 Andersen 1983 Parving 1996 Rossing 1996 Astrup et al Duration of nephropathy (years)

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39 Kliniske udfordringer hypotension og perifer perfusion ødemer

40 Epo mangel!?

41 Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin

42 Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin AK / magnyl behandling

43 Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin AK / magnyl behandling fodsår dicillin!!

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45 Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin AK / magnyl behandling fodsår dicillin!! urinsyre gigt - allopurinol

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47 Dagens budskaber.. Microalbuminuria a call for action Behandling af blodtryk og UAE Ødemer Lav hæmoglobin Dicillin Urinsyregigt

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51 Patienter diabetes kroniske sår god blodforsyning optimal aflastning

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53 Helingsrate i kroniske diabetiske fodsår

54 Teamwork i fodklinikken Date Presentation title 54