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lọc máu cho người bệnh đái tháo đường

(dialysis for diabetic patients)

HỘI NGHỊ KHOA HỌC LẦN THỨ I

HỘI LỌC MÁU VIỆT NAM

  • PGS.TS. Phạm Quốc Toản

Bệnh viện quân y 103

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agenda

  1. Epidemiology and concept of diabetic kidney disease
  2. Pathophysiology of dysglycemia and CKD
  3. Glucose blood control in hemodialyis patients
  4. Procedual of diabetic hemodialysis
  5. Conclussions

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burden of diabetes in the world

Source: World Health Organization, Global Report on Diabetes, April 2016

  1. Epidemiology and concept of diabetic kidney disease

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  1. Epidemiology and concept of diabetic kidney disease

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  1. Epidemiology and concept of diabetic kidney disease

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epidemiology and mortality of diabetic dialysis

  1. Epidemiology and concept of diabetic kidney disease

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concenpts

+ Diabetic nephropathy

(Bệnh thận do ĐTĐ)

​

+ Renal complications of diabetes

(Biến chứng thận do ĐTĐ)

​

+ Kidney injury in diabetes

(Tổn thương thận do ĐTĐ)

​

+ Diabetic kidney disease

(Bệnh thận ở BN ĐTĐ)

​

+ New onset diabetes in CKD

(ĐTĐ mới mắc ở BTMT)

​

  1. Epidemiology and concept of diabetic kidney disease

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2. Pathophysiology of dysglycemia and CKD

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morphology and structure change

2. Pathophysiology of dysglycemia and CKD

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2. Pathophysiology of dysglycemia and CKD

Natural history of diabetic nephropathy

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glucose meatbolism in the kidney

2. Pathophysiology of dysglycemia and CKD

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renal metabolism of insulin

2. Pathophysiology of dysglycemia and CKD

Endogenous insulin

Exogenous

insulin

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insulin resistence in chronic kidney disease

2. Pathophysiology of dysglycemia and CKD

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interactions between kidney disease and diabetes

2. Pathophysiology of dysglycemia and CKD

Hemodialysis

Peritoneal dialysis

High risk

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Definition:

+ Normoglycemia

+ A1c < 6%

+ or GA < 16%

+ without antidibetic drug

​

Prevalance:

+A1c: 20,7%

+GA: 18,6%

2. Pathophysiology of dysglycemia and CKD

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Assessment of glycaemic control

3. Glycaemic control in hemodialyis patients

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glucose blood control

Venous

capillary

3. Glycaemic control in hemodialyis patients

Non HD day

HD day

CGM

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1,5‑anhydroglucitol test

3. Glycaemic control in hemodialyis patients

https://glycomark.com/the-glycomark-test/what-do-test-results-mean/

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Glycated markers

3. Glycaemic control in hemodialyis patients

A1c

GA

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Markers on hemodialysis

3. Glycaemic control in hemodialyis patients

A1c

Glu

GA

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J shape of A1c in diabetic hemodialysis patients

3. Glycaemic control in hemodialyis patients

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corrected factor in hemodialysis

3. Glycaemic control in hemodialyis patients

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A1c target

3. Glycaemic control in hemodialyis patients

8,5%

7,1%

7,9%

6,5%

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Factors guiding decisions on individual A1c targets

3. Glycaemic control in hemodialyis patients

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3. Glucose blood control in hemodialyis patients

Burnt out diabetes

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Oral antidiabtetic drug

3. Glycaemic control in hemodialyis patients

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Insulin therapy in the hospital/dialysis unit

3. Glycaemic control in hemodialyis patients

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Insulin therapy in the hospital/dialysis unit

  • Insulin regimens: Reduce the dose by 50%
  • threetimes-daily preprandial injections: fast or ultrafast-acting insulin
  • twice-daily injections (morning and evening): premixed insulin
  • once-daily injection: intermediate- or longacting soluble insulin
  • Test glucose blood level: before and after HD each session

3. Glycaemic control in hemodialyis patients

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Patient factors influencing the selection of glucose-lowering drugs

3. Glycaemic control in hemodialyis patients

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time of initiation dialysis

4. Procedual of diabetic hemodialysis

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gfr of initiation dialysis

4. Procedual of diabetic hemodialysis

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10 – 14

ml.p.m

5 – 7

ml.p.m

gfr of initiation dialysis

ideal study

4. Procedual of diabetic hemodialysis

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gfr of initiation dialysis

4. Procedual of diabetic hemodialysis

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vascular assess in diabetic eskd

4. Procedual of diabetic hemodialysis

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Assessment of risk for hypoglycaemia

Glucose test

before

after

HD session

< 3,9 mmol/l

4. Procedual of diabetic hemodialysis

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algorithm for selecting antihyperglycemic drugs

4. Procedual of diabetic hemodialysis

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Insulin therapy in the hospital/dialysis unit

4. Procedual of diabetic hemodialysis

Glucose test

Insulin dose reduce

Intervention

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target control of diabetes in hd

  • Fasting blood glucose (predialysis) < 7,8 mmol/l
  • 1-hour postprandial glucose < 11,1 mmol/l
  • A1c: 7 – 8%

4. Procedual of diabetic hemodialysis

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Conclusion

  • Diabetes is main cause of ESKD, treated by HD
  • Glucose, insulin and other related factor are fluctuated
  • High risk of hypoglycaemia and hyperglycaemia
  • Burnt out diabetes may be presented in diabetic HD pts
  • Controversial biomarker of diabetes control in HD pts (A1c, GA, Glu)

Target A1c: 7 – 8%, AG: < 20%, Fasting Glu < 7,8 mmol/l

  • Insulin dose reduction to 50% in HD pts, some oral drug were avoided
  • Glucose test before and just end of HD session

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