Diabetic Nephropathy
Steno Diabetes Center
The magnitude of the problem 2010 2030 Total number of people with diabetes (age 20-79) Prevalence of diabetes (age 20-79) 285 million 438 million 6.6 % 7.8 %
Diabetes Mellitus 2010 Skøn over udbredelse i Danmark 26.000 140.000 125.000 50.000 Type 1 Type 2 Insulin behandlet Type 2 Diæt/tbl. behandlet Type 2 Ikke diagnosticeret
Critically important to protect this woman David Savage, Belfast
Diabetisk nefropati overblik.. Mikro-albuminuri a call for action Hvilke undersøgelser hvornår? Hvilken behandling? Kliniske udfordringer Leucopatch..
Urinary albumin excretion rate normo micro macro < 30 mg/24h 30-300 mg/24h > 300 mg/24h
Albuminuria (µg/min) Progression of Diabetic Renal Disease in Patients with Diabetes 2000 Overt nephropathy 40% 200 20 2 Microalbuminuria Normoalbuminuria Time (Years) 60%
U alb/cr (mg/g) Urinary albumin / creatinine (mg/g) day-to day variation 1200 1000 800 600 400 200 0 Follow-up (days)
2 min? Taler I med patienterne om nyresygdom? Hvad spørger I dem om?
Microalbuminuria is NOT only a test result, but a call for ACTION! 14 PHG, MS
Prevalence of late complications in 549 NIDDM patients aged < 76 years attending Hvidöre Hospital Normo- Micro- Macro- albuminuria Albuminuria 59 27 14 Hypertension 48 68 85 Retinopathy 6 10 25
Diabetic Maculopathy
Central vision loss
Prevalence of late complications in 549 NIDDM patients aged < 76 years attending Hvidöre Hospital Normo- Micro- Macro- albuminuria Albuminuria 59 27 14 Hypertension 48 68 85 Retinopathy 6 10 25 CHD 22 26 46
Proteinuria Predicts Stroke and CHD Events in Type 2 Diabetes 1 Survival curves for CVD mortality 40 Incidence of CVD (%) 0.9 0.8 0.7 A B 30 20 p<0.001 0.6 0.5 Overall: p<0.001 C 10 0 0 0 10 20 30 40 50 60 70 80 90 Stroke CHD Months events A: U-Prot <150 mg/l B: U-Prot 150 300 mg/l C: U-Prot >300 mg/l Miettinen H et al. Stroke. 1996;27:2033-2039.
Hjertekar sygdom findes ikke kun ét sted i kroppen
Prevalence of late complications in 549 NIDDM patients aged < 76 years attending Hvidöre Hospital Normo- Micro- Macro- albuminuria Albuminuria 59 27 14 Hypertension 48 68 85 Retinopathy 6 10 25 CHD 22 26 46 Foot ulcers 5 13 25 Neuropathy
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
The kidney
Glomerulus = the filtration unit
Normal glomerulus
Diabetic nephropathy
Måling af nyrefunktion = GFR 130 120 110 100 90 80 70 1 2 3 4 5 6
Glomerular filtration rate (ml/min/1.73 m 2 ) Progression of renal failure i 9 diabetic patients 100 50 10 End stage renal disease Jones et al, The Lancet 1979
Hæmodialyse
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 1 9 9 0-2 0 0 4 (p m p ) 30 Danish Kidney Database 25 T y p e 1 a n d T y p e 2 20 15 10 T y p e 1 5 T y p e 2 0 1990 1992 1994 1996 1998 2000 2002 2004
behandling?
Cardiovascular disease in diabetic nephropathy BP reduction (< 120/80) Diuretics Stop smoking ASA 75 mg x 1 Statins
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
Cumulative mortality (%) Mortality 100 75 Knowles 1971 Andersen 1983 Parving 1996 Rossing 1996 Astrup et al 2005 50 25 0 0 5 10 15 20 Duration of nephropathy (years)
Kliniske udfordringer hypotension og perifer perfusion ødemer
Epo mangel!?
Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin
Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin AK / magnyl behandling
Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin AK / magnyl behandling fodsår dicillin!!
Kliniske udfordringer hypotension og perifer perfusion ødemer haemoglobin AK / magnyl behandling fodsår dicillin!! urinsyre gigt - allopurinol
Dagens budskaber.. Microalbuminuria a call for action Behandling af blodtryk og UAE Ødemer Lav hæmoglobin Dicillin Urinsyregigt
Patienter diabetes kroniske sår god blodforsyning optimal aflastning
Helingsrate i kroniske diabetiske fodsår
Teamwork i fodklinikken Date Presentation title 54