Disclosure of Interest

MICHEL JADOUL
Scientific advice to companies:
Amgen, ZS-Pharma, Fresenius, Sanofi, Shire, Amgen,
Menarini
Travel refunds, congress registration fees:
Amgen
Research grant:
Amgen, Baxter, Fresenius, Janssen-Cilag, Roche

The details of each Disclosure of Interest are available at the Invited Speakers desk (located
in the Registration Area).

Albuminuria in diabetic patients :

prognosis and management
Professor Michel Jadoul
Cliniques Universitaires St. Luc
Universit Catholique de Louvain
Brussels, Belgium

Albuminuria in diabetics
Prognostic impact of albuminuria in general
and in diabetics
Is albuminuria measured in T2D?
How should albuminuria best be managed?

Prognostic value of GFR and albuminuria:

Cohorts and Subjects of CKD Consortium
Community based populations
With ACR data, 14 studies, n=105,872
With dipstick data, 10 studies, n=1,239,447

Populations at increased CVD risk (HTN, diab, CV)

10 studies, n=266,975

CKD cohorts
14 studies, n= 21,688

45 cohorts in total, >1.5 million subjects

Collaborative meta-analysis
Major publications: Lancet, KI, JAMA

Prognostic value of GFR and albuminuria:

Cohorts and Subjects of CKD Consortium
Community based populations
With ACR data, 14 studies, n=105,872
With dipstick data, 10 studies, n=1,239,447

Populations at increased CVD risk (HTN, diab, CV)

10 studies, n=266,975

CKD cohorts
14 studies, n= 21,688

45 cohorts in total, >1.5 million subjects

Collaborative meta-analysis
Major publications: Lancet, KI, JAMA
Matsushita et al, Lancet 2010

Adjusted relative risk of renal and cardiovascular outcomes

for GP cohorts with ACR

Levey et al, Kidney Int 2011

Staging of CKD (CGA staging)

Cause

Diabetes

GFR Categories
(ml/min/1.73m2)

G1

Albuminuria Categories
(ACR, mg/g)

90
A1

Hypertension

G2

60-89

Glom Disease

G3a

45-59

N to mildly increased
Dipstick neg to trace

A2
Transplant

G3b

30-44

Unknown

G4

15-29

G5

<15

30-299
Moderately increased
Dipstick trace to +

A3
etc

<30

300
Severely increased
Dipstick > +

Dialysis or serum creat X2

Albuminuria in diabetics
Prognostic impact of albuminuria in general
and in diabetics
Is albuminuria measured in T2D?
How should albuminuria best be managed?

75.6 % of pts with T2D have a urine test for

albuminuria within the 1st year after starting
antidiabetic medication

Albuminuria in diabetics
Prognostic impact of albuminuria in general
and in diabetics
Is albuminuria measured in T2D?
How should albuminuria best be managed
with currently available (registered) drugs?

20

Minimising CKD progression (and CV risk) BP control

ACR

A1

A2

<30mg/g

30-300 mg/g

A3
> 300 mg/g

Diabetic 140/90 mmHg 130/80 mmHg

(1B)
(2D)

130/80 mmHg
(2D)

Non
140/90 mmHg 130/80 mmHg
diabetic
(1B)
(2D)

130/80 mmHg
(2D)

ACE-I or ARB 1st choice

The anti-proteinuric effect of lisinopril is dose and time related,

and strongly dependent on dietary sodium restriction

Heeg et al, KI 1989

Low Salt intake= 50

High salt = 200 mmol/day

Salt restriction or diuretics :

similar potentiation of ACE-I effect

Addition of HCT ->

10% BP
40% proteinuria

Low sodium= 50 mmol/d

High sodium = 200 mmol/d

Buter et al, Nephrol Dial Transplant 1998

Dual RAAS blockade in CKD ?

28

Dual RAAS blockade ?

Nephro-protection : reducing proteinuria with
medium to long-term renoprotective effect (dialysis
later ... or never)
Nephro-risk: acute worsening of renal failure and
hyperK if intercurrent disease (gastroenteritis ++,..)
So block RAAS : YES but usually single agent (ACEi
or ARB) + possibly micro cardio dose of
spironolactone
Association ACE I + ARB : only if heavy proteinuria
( glomerular), with close, careful nephrology
follow-up in reliable patients
32

No BP differences between groups

Conclusions
Albuminuria = a strong , independent
prognostic marker of high risk of poor outcomes
Urinalysis still underused in the follow-up of
diabetic patients
Albuminuria /proteinuria can /should be
treated
- optimal BP control
- RAS blockade (usually single agent)
- low salt intake and /or diuretics
- other drugs ? (pentoxyfilline?)

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