Diabetic Kidney Disease

Question 1

What is he most common cause of death in persons with CKD?

Answer 1

CVD

Question 2

Per pt’s with DM and CKD, which type of medication should be considered for treatment of hyperglycemia and/or CVD events?

Answer 2

SGLT2 cotransporters

Question 3

What should initial antihypertensive treatment for pt’s with DM and CKD consist of?

Answer 3

An ACEi or ARB

Question 4

How is CKD defined?

Answer 4

Structural or functional abnormalities of the kidney for > 3 months using following criteria:

1. GFR < 60 mL/min
2. Persistent albuminuria, UACR >30 mg/g creatinine or > 3 mg/mmol creatinine
3. Albumin excretion rate > 30 mg/24 hours

OR

Other manifestations of kidney disease (urine sediment abnormalities, lyte and other abnormalities d/t tubular disorders, or h/o kidney transplant)

Question 5

True or false: All kidney disease found in patient’s with DM is Diabetic Kidney Disease (presence of albuminuria and/or reduced GFR <60)

Answer 5

False; presentation of DKD usually occurs w/ DM of long standing duration w/ progressive decline of GFR

Question 6

What is the cut off for moderately increased and severely increased albuminuria?

Answer 6

Moderate: 30-300 mg/g (3-30 mg/mmol

Severe > 300 mg/g (>30 mg/mmol)

Question 7

What is the most common risk factor for DKD?

Answer 7

Advanced age (given renal function naturally declines w/ increaing age)

Question 8

What ethnic groups are at high risk for DKD?

Answer 8

AA, hispanics, native americans, and asians

Evidence also supports genetic predisposition to DKD

Question 9

How often should pt’s with type 1 and type 2 DM be screened for DKD?

Answer 9

Type 1: 5 years after dx, annually thereafter

Type 2: At dx, annually thereafter, and during pregnancy

Question 10

What is the recommended screening method for screening for albuminuria

Answer 10

Measurement of the urinary albumin to creatinine ration (UACR) in a random spot urine collection

A normal UACR is defined as <30 mg/g creatinine

2 of 3 spot UACRS (preferably from first void urine) collected w/in 3-6 month period, must be abnormal to dx albuminuria

Question 11

What is the best overall index of kidney function?

Answer 11

GFR

The CKE Epidemiology Collaboration Equation is the preferred method to determine this

Question 12

In older adults w/ end stage illness such as ESRD, an A1c goal of < ____% may be appropriate to minimize risk of hypoglycemia

Answer 12

8.5%

Question 13

Which stages of CKD is Metformin approved for use for?

Answer 13

1-3

Question 14

Per pt’s with DM2 and DKD with GFR > 30 with severely increased albuminuria which oral DM med is rec’d to decrease risk of CKD progression, CV events (or both) independent of baseline A1c of A1c goals

Answer 14

SGLT-2 inhibitor

While evidence less robust with GLP-1 receptor agonists, they may also be considred in pt’s with CKD to reduce risk of CV events and/or progression of albuminuria

Question 15

Which DPP4 inhibitors should be used in caution with CKD patients due to increased risk for HF?

Answer 15

Saxagliptin, alogliptin

Question 16

Which oral SU agents may be considered if pt’s are expected to have endogenous insulin production remaining?

Answer 16

Glipizie or glimepiide–> preferred to other agents in the pharmacologic class d/t short duration of action and limited ability to accumulate in renal impairment. Glyburide should NOT be used with GFR <60 and should be avoided in older pt’s with DM2

Question 17

What class of oral medication is typically not recommended in CKD due to potential for fluid retention?

Answer 17

TZD

Specifically, use of rosiglitazone has demonstrated increased risk for acute MI

Question 18

Why does recurrent or severe hypoglycemia happen in CKD?

Answer 18

As kidney function declines, exogenous insulin acts longer and in an unpredictable manner. Additionally, anorexia that may present in advanced stages of CKD prior to starting dialysis will result in dietary changes

Question 19

To slow the progression of CKD, a BP < ____ is recommended for adults with HTN by the CKD and ACC/ADA

Answer 19

130/80 mmHg

Question 20

True or False: An ACEi is recommended as concomitant therapy with an ARB

Answer 20

False; this is not recommended as there has found to be no benefit and increases risk of adverse events such as hyperkalemia and AKI

Question 21

What is the recommended restriction of dietary sodium to reduce BP and associated CV risk?

Answer 21

<1500-2300 mg/dL and implementation of DASH diet

Question 22

What are current recommendations to initiating statin therapy for primary prevention of CVD in adults age 40-75 with DM and LDL > 70?

Answer 22

Moderate intensity statin therapy should be started for primary prevention of CVD regardless of pt’s estimated 10 year risk of ASCVD

Further intensification should be considered in adults with DM & multiple risk factors for CVD or age 50-75 years, as well as those w/ established CVDq

Question 23

Why is initiation of stain therapy in pt’s with advanced CKD not recommended?

Answer 23

Lower rate of deaths due to atherosclerotic causes in dialysis pt’s and lack of benefit from statin initiation in RCTs.

Question 24

True or false: low CHO or very low CHO diet plans are recommended for patient with renal impairment

Answer 24

False; they are not recommended

Question 25

What is the recommended protein intake for pt’s with DKD?

Answer 25

15-20% of total kcal intake, but should not exceed 1.3 g/kg/day

The updated ADA consensus report on nutrition therapy for pt’s with non dialysis dependent DKD does not recommend restricting dietary protein to less than average protein intake

Question 26

What is the preferred antihyperglycemic medication for patient’s on HD?

Answer 26

Insulin

Can be difficult to predict for pt on HD

Question 27

What is significant about GDH-PQQ cofactor based test trips?

Answer 27

They can not distinguish between glucose and non glucose sugars (maltose, xylose, galactose). As a result, these non glucose sugars my be read by such test strips as a falsely elevated serum glucose level, masking a hypoglycemic epidote or causing inappropriately aggressive insulin management

Question 28

Following kidney transplant what factors may alter BG?

Answer 28

Increased degree of functionality, therapy for prevention of transplant rejection (costeroids, etc), increased appetite/ability to eat more liberal diet

Question 29

What is Post transplantation DM?

Answer 29

Occurs when dx of DM is made following solid organ transplant

Those at risk for PTDM should be screened for post transplant glucose abnormalities with OGTT, which is considered goal standard for dx’ing PTDM