당뇨병, 혹시 콩팥은? 당뇨병성 신증의 신장내과 치료 전략 당뇨병, 혹시 콩팥은? 당뇨병성 신증의 신장내과 치료 전략 Sejoong Kim Seoul National University Bundang Hospital

국내 말기 신부전 국내 말기 신부전 원인 질환 원인질환별 사망율

당뇨병과 신장 당뇨병은 전세계적으로 많고 증가하고 있으며, 연관 질환의 유병율 (morbidity)와 사망률이 높고, 사회 경제적인 부담이 크다. 2. 국내 말기 신부전의 가장 많은 원인이 당뇨성 신병증이다. 3. 당뇨성 말기 신부전의 사망률은 기타 질환에 의한 것 보다 높다 4. 당뇨성 신병증은 당뇨병 환자의 30-35%에서 발견된다. 5. 당뇨성 신병증은 임상적으로 당뇨성 망막증, 오랜 유병기간, 알부민뇨가 특징이며, 급격한 단백뇨의 증가 혹은 사구체성 혈뇨는 드물다.

Changing epidemiology of T2DM Aging  increased prevalence of T2DM and co-morbid CKD Young and obesity with T2DM, risk of DM complication including CKD. Low to middle income contries, increase in T2DM and risk of CKD Is also high. CVD in T2DM improved, not associated with substantial reduction in DM-CKD Absence of new and effective renoprotecive interventions.  Increase in prevalence of T2DM and increase in prevalence of CKD. NATURE REVIEWS | NEPHROLOGY, 2016

Renal replacement modality selection Glycemic control European Renal Best Practice Renal replacement modality selection Glycemic control Cardiovascular risk management

8.5% 7.0% 8.0% 7.5%

JAMA 2014;312(24):2668-75

HT management in CKD Albuminuria BP target Preferred agent KDIGO 2012 guideline Albuminuria BP target Preferred agent < 30 mg/day ≤ 140/90 mmHg None 30-300 mg/day ≤ 130/80 mmHg ACEI or ARB > 300mg/day 1B 2D 2C ESC: patients with diabetic or non-diabetic CKD: < 140/90 mmHg (IIa) For subjects with proteinuria: SBP < 130mmHg (IIb) JNC VIII: 140/90 regardless of proteinuria Based on the evidence of KDIGO guideline, which is a global guideline for HT management in CKD. They specified that the patient without proteinuria, the blood pressure target should be revised 140, without any preferred agent, the patient with a significant proteinuria, the target BP should be 130 of 80 with a preferred agent. Kidney Int 2012;2(Suppl):337-414

Pressure control vs. Metabolic control UK Prospective Diabetes Study (UKPDS) 8 years for glycemic control  positive fallout on microvascular complication 2-3 years for better control of BP and Lipids Life expectancy ?

J. Clin. Med. 2015, 4, 1908-1937

Blockade of the RAAS is a proven cornerstone of therapy

Careful for hyperkalemia and acute kidney injury

hyperkalemia

Anemia

Take home messages CKD stage 3B+ (eGFR 45-) Metabolic complications Renal replacement therapy Hypoglycemia risk Hypertension: RAAS inhibitor and risks Metabolic complications Cholesterol, uric acid, vitamin D Potassium, phosphorus, acidosis Anemia (+ VDRA, V2RA)