Bệnh thận Đái tháo đường (Diabetic Kidney Disease)

1. HUỲNH TẤN TÀI
bshttai@gmail.com
TP.HCM, 05/2017 1Diabetic Kidney Disease 2017 - Dr Tai

2. 
- Chẩn đoán, Chẩn đoán phân biệt bệnh thận ĐTĐ
- Tầm soát bệnh thận ĐTĐ
- Can thiệp đa yếu tố (Multifactorial Intervention
Strategy) trên BN bệnh thận ĐTĐ
• Kiểm soát đường huyết trên BN bệnh thận ĐTĐ
• Kiểm soát huyết áp trên BN bệnh thận ĐTĐ
• Kiểm soát RL lipid máu trên BN bệnh thận ĐTĐ
• Quản lý dinh dưỡng trên BN bệnh thận ĐTĐ
VẤN ĐỀ
2Diabetic Kidney Disease 2017 - Dr Tai

3. - Bệnh thận ĐTĐ:
• Diabetic Kidney Disease
• Diabetic Nephropathy
- Tiểu albumin (albuminuria); Tiểu protein
(Proteinuria)
- Tiểu abumin vi lượng (microalbuminuria), Tiểu
albumin đại lượng (macroalbuminuria) (KDOQI
2007)
- Tiểu abumin mức độ trung bình, Tiểu albumin
mức độ nặng (KDIGO 2012)
CÁC THUẬT NGỮ
3Diabetic Kidney Disease 2017 - Dr Tai

4. 
Albumin niệu & Protein niệu
4Diabetic Kidney Disease 2017 - Dr Tai

5. 
Phân loại albumin niệu
TL: Bộ Y tế (2015), Hướng dẫn chẩn đoán và điều trị các bệnh Thận-Tiết niệu.
KDIGO 2012
Bình thường
hoặc Tiểu
albumin nhẹ
Tiểu albumin
trung bình
Tiểu albumin
nặng
KDOQI 2007
Không tiểu
albumin
Tiểu albumin
vi lượng
Tiểu albumin
đại lượng
Tỷ lệ
albumin/creatinin
(mg/g)
<30 30-300 >300
Albumin niệu 24h
(mg/24h)
<30 30-300 >300
5Diabetic Kidney Disease 2017 - Dr Tai

6. 
Screening for albuminuria
TL: NKF-KDOQI (2007), Diabetes and Chronic Kidney Disease.
NKF-KDOQI 2007
6Diabetic Kidney Disease 2017 - Dr Tai

7. 
Đặc trưng của tiểu protein ở
BN ĐTĐ
TL: Bộ Y tế (2015), Hướng dẫn chẩn đoán và điều trị các bệnh Thận-Tiết niệu.
7Diabetic Kidney Disease 2017 - Dr Tai

8. 
TL: Ralph AD et al (2015), International Textbook of Diabetes Mellitus, 4th Ed, Wiley Blackwell, USA.
8Diabetic Kidney Disease 2017 - Dr Tai

9. 
9Diabetic Kidney Disease 2017 - Dr Tai

10. 
10Diabetic Kidney Disease 2017 - Dr Tai

11. 
Diagnosis of DKD
TL: NKF-KDOQI (2007), Diabetes and Chronic Kidney Disease.
NKF-KDOQI 2007
11Diabetic Kidney Disease 2017 - Dr Tai

12. 
Think of
Non-Diabetic Kidney Disease
TL: NKF-KDOQI (2007), Diabetes and Chronic Kidney Disease.
NKF-KDOQI 2007
12Diabetic Kidney Disease 2017 - Dr Tai

13. 
13Diabetic Kidney Disease 2017 - Dr Tai

14. 
14Diabetic Kidney Disease 2017 - Dr Tai

15. 
DIỄN TIẾN CỦA BỆNH THẬN DO ĐÁI THÁO ĐƯỜNG
15Diabetic Kidney Disease 2017 - Dr Tai

16. 
BỆNH CẦU THẬN NGUYÊN PHÁT Ở BN ĐÁI THÁO ĐƯỜNG
16Diabetic Kidney Disease 2017 - Dr Tai

17. 
CÁC BỆNH THẬN-NIỆU CÓ THỂ GẶP TRÊN BN ĐÁI THÁO ĐƯỜNG
17Diabetic Kidney Disease 2017 - Dr Tai

18. 
Screening for
Diabetic Kidney Disease
TL: NKF-KDOQI (2007), Diabetes and Chronic Kidney Disease.
NKF-KDOQI 2007
18Diabetic Kidney Disease 2017 - Dr Tai

19. 
Screening for
Diabetic Kidney Disease
TL: NKF-KDOQI (2007), Diabetes and Chronic Kidney Disease.
NKF-KDOQI 2007
19Diabetic Kidney Disease 2017 - Dr Tai

20. 
Screening for
Diabetic Kidney Disease
ADA 2017
TL: ADA (2017), Diabetes and Chronic Kidney Disease.
20Diabetic Kidney Disease 2017 - Dr Tai

21. 
KDIGO 2012
21Diabetic Kidney Disease 2017 - Dr Tai

22. 
Yếu tố nguy cơ thúc đẩy bệnh
thận trên BN ĐTĐ
O’Connor A.S. et al (2005), Am J Kid D, 46(4):766-7322Diabetic Kidney Disease 2017 - Dr Tai

23. 
Management of CKD in diabetes
ADA 2017
TL: ADA (2017), Diabetes and Chronic Kidney Disease.
23Diabetic Kidney Disease 2017 - Dr Tai

24. 
Multifactorial Intervention Strategy
 MANAGEMENT OF HYPERGLYCEMIA
 MANAGEMENT OF HYPERTENTION
 MANAGEMENT OF DISLIPIDEMIA
 MANAGEMENT OF NUTRITIONAL CARE
24Diabetic Kidney Disease 2017 - Dr Tai

25. 
Management of Hyperglycemia
NKF-KDOQI 2007(*)
KDOQI 2012 Updates(**)
(*)
(**)
25Diabetic Kidney Disease 2017 - Dr Tai

26. 
Management of Hyperglycemia
ADA 2017(**)
(**)
26Diabetic Kidney Disease 2017 - Dr Tai

27. 
ADA 2017(*)
Bộ Y tế 2015(**)
ADA 2017(*)
(**) Bộ Y tế (2015), Hướng dẫn chẩn đoán và điều trị các bệnh Thận-Tiết niệu.
(*) 27Diabetic Kidney Disease 2017 - Dr Tai

28. 
Management of Hyperglycemia
KDOQI 2012 Updates(**)
(**) 28Diabetic Kidney Disease 2017 - Dr Tai

29. 
Management of Hyperglycemia
NKF-KDOQI 2007(*)
(*)
29Diabetic Kidney Disease 2017 - Dr Tai

30. 
Management of Hyperglycemia
TYPE 1 DIABETES
The DCCT 1993 (Diabetes Control and Complications Trial):
- A Multicenter Randomized Clinical Trial
- Numbers of patients: 1,441
- Mean follow-up time: 6.5 yrs
- Two groups:
• Primary Prevention: no retinopathy, urinary AER<28mcg/min: 726 pts
• Secondary Intervention: retinopathy with/without microalbuminuria,
normal GFR: 715 pts
- Sub-groups: Intensive Treatment vs Conventional Treatment
The DCCT Research Group (1993), N Engl J Med, 329(14):977-86
30Diabetic Kidney Disease 2017 - Dr Tai

31. 
Measurements of HbA1C in patients with type 1 DM receiving Intensive
or Conventional therapy
The DCCT Research Group (1993), N Engl J Med, 329(14):977-8631Diabetic Kidney Disease 2017 - Dr Tai

32. 
A
(Primary Prevention)
B
(Secondary Intervention)
54%
76%
Cumulative incidence of a sustained change in retinopathy in patients with type 1
DM receiving Intensive or Conventional therapy
New Onset
Retinopathy
Progression of
Retinopathy
Neuropathy: at five years
- Primary Prevention: Appearance Reduction: 69% (P=0.006)
- Secondary Intervention: Appearance Reduction: 57% (P<0.001)
The DCCT Research Group (1993), N Engl J Med, 329(14):977-86
32Diabetic Kidney Disease 2017 - Dr Tai

33. 
A
(Primary Prevention)
B
(Secondary Intervention)
Solid line: Urinary Albumin Excretion of 40mg/24h or greater. Dashed line: Urinary Albumin Excretion of 300mg/24h or greater.
RR Reduction of New-Onset Macro-albuminuria: 84% (95%CI: 58-94%, p=0.0002)(*)
RR Reduction of Progression for Micro- to Macro-albuminuria: 83% (95%CI: 21-
96%, p=0.0236).(*)
Reduction of
Occurrence: 34%
Reduction of
Occurrence: 43%
The DCCT Research Group (1993), N Engl J Med, 329(14):977-86
56%
Cumulative incidence of UAE≥300mg/24hrs (Dashed line) and ≥40mg/24hrs
(Solid line) in patients with type 1 DM receiving Intensive or Conventional therapy
(*)
33Diabetic Kidney Disease 2017 - Dr Tai

34. 
The DCCT/EDIC 2005 in type 1 DM Patients
The DCCT/EDIC Study Research Group (2005), N Engl J Med, 353(25):2643-53
NKF-KDOQI 2007(*)
The DCCT/EDIC: The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications
34Diabetic Kidney Disease 2017 - Dr Tai

35. 
The DCCT/EDIC 2005 in type 1 DM Patients
RR Reduction: 59%
Macro-
35Diabetic Kidney Disease 2017 - Dr Tai

36. TYPE 2 DIABETES
THREE CLASSIC STUDIES:
- The Kumamoto Study (8yrs): 11.5% vs 43.5%, p=0.022
- The UKPDS (9yrs): RR Reduction 24%, p=0.0006
- The VA Cooperative Study (2yrs): 17% vs 35%, p=0.05
THREE RECENT STUDIES:
- The ADVANCE: RR Reduction 9% (23.7% vs 25.7%)
- The ACCORD: RR Reduction 21% (12.5% vs 15.3%)
- The VADT: RR Reduction 32% (10.0% vs 14.7%)
NKF-KDOQI 2007; KDOQI 2012 Updates
REDUCTION OF MICROALBUMINURIA OCCURRENCE
36Diabetic Kidney Disease 2017 - Dr Tai

37. TYPE 2 DIABETES
THREE CLASSIC STUDIES:
- The Kumamoto Study (8yrs): 11.5% vs 32%, p=0.04
- The UKPDS (9yrs): 4.4% vs 6.5%, p>0.05
- The VA Cooperative Study (2yrs): 12% vs 36%, p=0.04
THREE RECENT STUDIES:
- The ADVANCE: RR Reduction 30% (2.9% vs 4.1%)
- The ACCORD: RR Reduction 32% (2.7% vs 3.9%)
- The VADT: RR Reduction 37% (7.6% vs 12.1%)
NKF-KDOQI 2007; KDOQI 2012 Updates
REDUCTION OF MACROALBUMINURIA OCCURRENCE
37Diabetic Kidney Disease 2017 - Dr Tai

38. 
Stratton et al (UKPDS 35), BMJ, 2000, 321:405-12.
The UKPDS 35 (type 2 DM)
38Diabetic Kidney Disease 2017 - Dr Tai

39. 
The EDIC/DCCT Follow-up Study
- eGFR<60ml/min/1.73m2: RR Reduction: 50% (1.6 vs
3.0/1000 person-years, p=0.0006)
- eGFR<45ml/min/1.73m2: RR Reduction: 50% (1.6 vs
2.5/1000 person-years, p=0.045)
- eGFR<30ml/min/1.73m2: RR Reduction: 44% (0.8 vs
1.5/1000 person-years, p=0.088)
- ESRD: RR Reduction: 51% (0.5 vs 1.1/1000 person-
years, p=0.098)
NKF-KDOQI 2007; KDOQI 2012 Updates
REDUCE THE RATE OF DECREASE IN GFR???
39Diabetic Kidney Disease 2017 - Dr Tai

40. 
The UKPDS Study
NKF-KDOQI 2007; KDOQI 2012 Updates
REDUCE THE RATE OF DECREASE IN GFR???
40Diabetic Kidney Disease 2017 - Dr Tai

41. 
The ADVANCE, The ACCORD, The VADT
NKF-KDOQI 2007; KDOQI 2012 Updates
REDUCE THE RATE OF DECREASE IN GFR???
41Diabetic Kidney Disease 2017 - Dr Tai

42. 
Kiểm soát đường huyết trên BN Suy
thận mạn GĐ cuối
NKF-KDOQI 2007
42Diabetic Kidney Disease 2017 - Dr Tai

43. 
Dose Adjustment in CKD
NKF-KDOQI 2007; KDOQI 2012 Updates
43Diabetic Kidney Disease 2017 - Dr Tai

44. 
Dose Adjustment in CKD
NKF-KDOQI 2007; KDOQI 2012 Updates
44Diabetic Kidney Disease 2017 - Dr Tai

45. 
Dose Adjustment in CKD
NKF-KDOQI 2007; KDOQI 2012 Updates
45Diabetic Kidney Disease 2017 - Dr Tai

46. 
Dose Adjustment in CKD
BỘ Y TẾ 2015
46Diabetic Kidney Disease 2017 - Dr Tai

47. 
Thuốc kiểm soát đường huyết nào có
lợi cho THẬN???
ADA 2017
- SGLT2-inhibitors
- GLP-1 Receptor Agonist
- DPP-4 inhibitors
47Diabetic Kidney Disease 2017 - Dr Tai

48. 
Thuốc kiểm soát đường huyết nào có
lợi cho THẬN???
ADA 2017
48Diabetic Kidney Disease 2017 - Dr Tai

49. 
Thuốc kiểm soát đường huyết nào có
lợi cho THẬN???
ADA 2017
49Diabetic Kidney Disease 2017 - Dr Tai

50. 
EMPA-REG OUTCOME
50Diabetic Kidney Disease 2017 - Dr Tai

51. 
51Diabetic Kidney Disease 2017 - Dr Tai

52. 
52Diabetic Kidney Disease 2017 - Dr Tai

53. 
53Diabetic Kidney Disease 2017 - Dr Tai

54. 
Multifactorial Intervention Strategy
 MANAGEMENT OF HYPERGLYCEMIA
 MANAGEMENT OF HYPERTENTION
 MANAGEMENT OF DISLIPIDEMIA
 MANAGEMENT OF NUTRITIONAL CARE
54Diabetic Kidney Disease 2017 - Dr Tai

55. 
Management of Hypertension
NKF-KDOQI 2007(*)
(*) 55Diabetic Kidney Disease 2017 - Dr Tai

56. 
NKF-KDOQI 2007(*)
(*)
Blood Pressure level and rate of GFR decline in controlled trials of DKD
56Diabetic Kidney Disease 2017 - Dr Tai

57. 
Blood Pressure Target
NKF-KDOQI 2007(*)
(*) 57Diabetic Kidney Disease 2017 - Dr Tai

58. KDIGO 2012(*)
Blood Pressure Target
58Diabetic Kidney Disease 2017 - Dr Tai

59. 
59Diabetic Kidney Disease 2017 - Dr Tai

60. 
ADA 2017(**)
(**)
Blood Pressure Target
60Diabetic Kidney Disease 2017 - Dr Tai

61. 
Which medications are recommended for
DKD patients with Hypertension?
• NKF-KDOQI, 2007
• KDIGO, 2012
• BỘ Y TẾ, 2015
• ADA, 2017
61Diabetic Kidney Disease 2017 - Dr Tai

62. 
Which medications are recommended for
DKD patients with Hypertension?
NKF-KDOQI 2007(*)
(*)
62Diabetic Kidney Disease 2017 - Dr Tai

63. 
Which medications are recommended for
DKD patients with Hypertension?
NKF-KDOQI 2007(*)
(*)
63Diabetic Kidney Disease 2017 - Dr Tai

64. 
TYPE 2 DIABETIC KIDNEY DISEASE
64Diabetic Kidney Disease 2017 - Dr Tai

65. 
BỘ Y TẾ 2015
65Diabetic Kidney Disease 2017 - Dr Tai

66. 
Which medications are recommended for
DKD patients with Hypertension?
KDIGO 2012(*)
66Diabetic Kidney Disease 2017 - Dr Tai

67. 
TL: Ralph AD et al (2015), International Textbook of Diabetes Mellitus, 4th Ed, Wiley Blackwell, USA.
International Textbook of Diabetes, 4thEd, 2015
67Diabetic Kidney Disease 2017 - Dr Tai

68. 
ADA 2017(**)
(**)
Which medications are recommended for
DKD patients with Hypertension?
68Diabetic Kidney Disease 2017 - Dr Tai

69. 
ADA 2017(*)
(*)
Which medications are recommended for
DKD patients with Hypertension?
Two clinical trials studied the combination of
ACE inhibitors and ARBs and found NO
BENEFITS on CVD or DKD, and the drug
combination had HIGHER ADVERSE EVENT
rates (hyperkalemia and/or acute kidney
injury)(**)
(**) ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for
vascular events. N Engl J Med 2008;358:1547-1559. 69Diabetic Kidney Disease 2017 - Dr Tai

70. 
70Diabetic Kidney Disease 2017 - Dr Tai

71. 
Multifactorial Intervention Strategy
 MANAGEMENT OF HYPERGLYCEMIA
 MANAGEMENT OF HYPERTENTION
 MANAGEMENT OF DISLIPIDEMIA
 MANAGEMENT OF NUTRITIONAL CARE
71Diabetic Kidney Disease 2017 - Dr Tai

72. 
Management of Dislipidemia
NKF-KDOQI 2007(*)
(*)
(**)
KDOQI 2012 Updates(**)
72Diabetic Kidney Disease 2017 - Dr Tai

73. 
NKF-KDOQI 2007(*)
(*)
Management of Dislipidemia
73Diabetic Kidney Disease 2017 - Dr Tai

74. 
Dose adjustments for lipid lowering medicines in DKD
KDOQI 2012 Updates
74Diabetic Kidney Disease 2017 - Dr Tai

75. 
BỘ Y TẾ 2015
Management of Dislipidemia
75Diabetic Kidney Disease 2017 - Dr Tai

76. 
TL: Scott J Gilbert et al (2014), National Kidney Foundation’s Primer on Kidney Diseases, 6th Ed, Elsevier Saunders, USA
National Kidney Foundation’s Primer on Kidney Diseases, 6thEd, 2014
76Diabetic Kidney Disease 2017 - Dr Tai

77. 
Ý NGHĨA CỦA GIẢM ALBUMIN
NIỆU TRÊN BỆNH NHÂN ĐÁI
THÁO ĐƯỜNG???
77Diabetic Kidney Disease 2017 - Dr Tai

78. 
ALBUMIN NIỆU TRÊN BN ĐÁI THÁO ĐƯỜNG
78Diabetic Kidney Disease 2017 - Dr Tai

79. 
Mức đạm niệu và nguy cơ
suy thận trên BN ĐTĐ type 2 (IDNT)
79Diabetic Kidney Disease 2017 - Dr Tai

80. 
Giảm tiểu đạm làm chậm tiến triển
của suy thận (IDNT)
80Diabetic Kidney Disease 2017 - Dr Tai

81. 
Giảm đạm niệu tương đồng với giảm biến chứng
tim mạch trên BN ĐTĐ type 2 (RENAAL)
81Diabetic Kidney Disease 2017 - Dr Tai

82. 
Annual transition rates with 95% CI through the stages of
nephropathy & to death from any cause (The UKPDS 64)
Adler et al (UKPDS 64), Kidney Int 2003;63(1):225-232.
UKPDS 64
Subjects: 5097
Median follow-up: 10.4 yrs
82Diabetic Kidney Disease 2017 - Dr Tai

83. 
 MANAGEMENT OF HYPERGLYCEMIA
 MANAGEMENT OF HYPERTENTION
 MANAGEMENT OF DISLIPIDEMIA
 MANAGEMENT OF NUTRITIONAL CARE
Multifactorial Intervention Strategy
83Diabetic Kidney Disease 2017 - Dr Tai

84. 
Nutritional Management
ADA 2017(*)
(*)
BỘ Y TẾ(**)
(**) Bộ Y tế (2015), Hướng dẫn chẩn đoán và điều trị các bệnh Thận-Tiết niệu.
84Diabetic Kidney Disease 2017 - Dr Tai

85. 
NKF-KDOQI 2007(*)
Effects of reduced dietary protein intake
85Diabetic Kidney Disease 2017 - Dr Tai

86. 
Multifactorial Intervention Strategy
NKF-KDOQI 2007(*)
(*)
86Diabetic Kidney Disease 2017 - Dr Tai

87. 
Multifactorial Intervention Strategy:
STENO-2 Trial
Gaede P, et al, N Engl J Med, 2008, 358:580-91
87Diabetic Kidney Disease 2017 - Dr Tai

88. 
Multifactorial Intervention Strategy:
STENO-2 Trial
Gaede P, et al, N Engl J Med, 2008, 358:580-91 88Diabetic Kidney Disease 2017 - Dr Tai

89. 
NKF-KDOQI 2007(*)
(*)
89Diabetic Kidney Disease 2017 - Dr Tai

90. 
BỘ Y TẾ 2015(*)
(*) Bộ Y tế (2015), Hướng dẫn chẩn đoán và điều trị các bệnh Thận-Tiết niệu.
90Diabetic Kidney Disease 2017 - Dr Tai

91. 
THANKS FOR YOUR
ATTENTION!
91Diabetic Kidney Disease 2017 - Dr Tai