This document provides an overview of chronic kidney disease and diabetes, current guidelines for treatment, and the role of registered dietitian nutritionists. It discusses that chronic kidney disease is commonly caused by diabetes and that tight glycemic control and low-protein diets can help slow disease progression. Registered dietitian nutritionists play an important role in educating patients on nutrition therapy, such as carbohydrate counting and limiting sodium, to manage both their diabetes and kidney disease.

1. Continuing Education:
Renal and Diabetes
Alisa McAleer, Dietetic Intern
December 15, 2014
Southern Regional Medical Center

2. Outline
• Chronic Kidney Disease and Diabetes
• Recommendations & guidelines: Glycemic Control and Protein
• For the practicing RDN
• Patient education and counseling

3. 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

4. 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

5. Kidneyabc.com
Diabetic
Nephropathy

6. 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

7. Renal & Diabetes
Current Regulations and Guidelines

8. 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%

9. 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!

10. 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

11. Renal and Diabetes
The RDN

12. RDN Skill Level
• Competent, proficient and expert
• Certificate of Training Program in CKD Nutrition Management
• CDR’s Board Certification in Renal Nutrition

13. Diet Intervention
• Kidney disease
• Uremia
• Hypertension
• Edema
• Hyperkalemia
• Hyperlipidemia
• Blood glucose

14. 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

15. 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

16. Summary
• Early detection
• Proper screening
• Management

17. 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