Speaker: Kim Kelly, PharmD, BCPS, FCCP, CDTC, CPC, CEC
Sleep Apnea and Diabetes: More than just a sleepless night!
Webinar Description: Obstructive sleep apnea (OSA) is associated with the development of type 2 diabetes due to altered glucose metabolism and promotion of insulin resistance. There is evidence to suggest that untreated OSA may have a negative glycemic impact in people with type 2 diabetes. Kim Kelly, PharmD, BCPS, FCCP, CDTC, CPC, CEC discusses the association between OSA and type 2 diabetes.
Speaker: Alexis Chettiar, ACNP-BC, PhD
Nutritional Recommendations for Renal Disease and Diabetes
Webinar Description: Alexis Chettiar, ACNP-BC, PhD discusses nutritional recommendations for people with renal disease and diabetes. Renal disease and diabetes are growing epidemics, and both are managed with a multifaceted approach inclusive of nutritional modifications.
Nutritional Recommendations for Renal Disease and Diabetes Q&A
with Alexis Chettiar ACNP-BC, PhD
1. Is there a concern with phosphorous intake?
Yes, particularly in late chronic kidney disease (CKD) 4 and CKD 5.
2. In our kidney clinic we use dietary strategies (with success) to reduce potassium rather than discontinue/decreasing ACE/ARBs.
This can be successful in many cases, however individual physiology and ability/willingness to restrict dietary potassium varies widely.
3. We don't recommend switching to refined grains as the phosphorus content in whole grains is not very well absorbed compared to phosphate additives in processed foods.
Patients should be steered towards additive-free refined carbs to minimize dietary phosphorous. If a patient is going to consume phosphorous, the type found in whole grains and legumes is less well-absorbed than phosphorous used as an additive. However, most patients will have to restrict both types of phosphorous to successfully keep their phosphorous in goal once they have CKD 5.
4. If eGFR at 90 indicates the start of issue how far above 90 do we start to get concerned?
Patients are considered to have CKD when they have an eGFR persistently (two labs > 3 months apart) less than 90. We should be concerned when a patient develops CKD, as early intervention can significantly improve long-term outcomes.
5. I have noticed that many of my patients with diabetes who have gone on dialysis no longer need insulin. Can you speak about this?
Kidneys play an important role in metabolizing and excreting insulin. When the kidneys no longer work (as for patients who are on dialysis), the insulin they have circulating, whether exogenous or endogenous, is active for much longer. Thus, requirements for insulin dosing diminishes significantly and many patients no longer require insulin when they develop renal failure.
6. Stage 4 CKD, protein 1-1.5 gm/kg for all patients or just those with diabetes? I just passed board exam and this is a surprise to me.
Guidance varies depending upon the reference source. This is a general rule of thumb that must be tailored to the clinical context. A moderate protein intake is generally recommended for patients with CKD 4, whether they have diabetes or not.
7. Does dialysis filter out insulin?
Yes. Dynamics of glycemic control in end stage renal disease (ESRD) patients are very complex.
8. I was taught to limit foods with added phosphorous before limiting foods with natural phosphorous like nuts/legumes/whole grains because natural phosphorous is less absorbed and added phosphorous is 100% absorbed. Your thoughts?
9. Are you calculating 1-1.5gm/kg protein daily based on adjusted body weight?
10. Is there an ideal time to take insulin while on dialysis - before or after dialysis?
This is a complex question and depends on multiple factors. UpToDate provides an excellent summary.
11. What would be the amount of phosphorus a day that we are looking for? I am also wondering how you counsel people who may be vegan.
There isn't a standardized daily dose of phosphorous for ESRD patients because the same dose consumed will result in a different serum phosphorous levels for different individuals. Dietary guidance is based on serum phosphorous and patients are generally advised to increase or decrease their consumption to achieve the goal phosphorous (3.5-5.5 mg/dL).
12. Wild fish – low phosphorous but high potassium?
Yes, one 3.5 ounce serving has potassium almost equivalent to a banana. Counseling must be individualized. Many individuals struggle with maintaining phosphorous in goals but don't have issues with potassium and vice versa.
13. What are alternatives to refined products since those are not healthy?
Vegetables and fruits that are low in potassium and phosphorous, but there aren't many.
14. I have found peanut butter on the acceptable foods lists for patients with CKD. These resources have come from CKD clinics. Why is this?
Not sure why that would be. Peanuts are quite high in phosphorous.
15. Do you have a general list of foods to avoid/foods to eat that incorporates all of the recommendations you've covered in one easy to use document?
See the last slide with additional resources. National Kidney Foundation, Davita, and Fresenius all have good resources.
16. Aside from controlling blood pressure and glucose, are there other lifestyle modifications that directly protect or help preserve kidney function? Also, are there dietary recommendations for CKD stages 1-3.
Heart-healthy lifestyle modifications are important for moderation of cardiovascular risk and have some side benefits for renal health. A plant-based diet tends to yield a higher venous bicarbonate level, which can slow CKD progression. No dietary recommendations in CKD 1-3 related to kidney disease, however there may be dietary recommendations for co-morbid conditions such as diabetes and hypertension.
17. What about a glass of wine or one hard liquor drink when out to dinner?
Generally not recommended for ESRD patients with diabetes due to 1) medication interactions 2) glycemic control 3)blood pressure effects. Beer is high in phosphorous. Hard alcohol and wine are lower phosphorous alcohol choices for ESRD patients.
18. Important to keep in mind cooked vs uncooked vegetables as a serving of a raw vegetable can be much lower in potassium than a serving of cooked.
Good point, thanks.
19. Is pork a good option for CKD 4 patients?
Yes, although lean white meat is considered best for cardiovascular health.
20. Is seafood a good option for CKD 4 patients?
Comparable to lean meats in phosphorous, but high in cholesterol.
21. Are we concerned about BUN anymore?
Less so. Not part of diagnostic criteria for CKD, and is subject to influence from non-renal factors.
22. How is stage 1 kidney disease diagnosed if kidney function is normal?
Structural or functional abnormalities in kidneys. Example - polycystic kidney disease with preserved renal function or normal eGFR with proteinuria.
23. What are your thoughts on post-transplant requirements?
Good question, but beyond the scope of this talk.
24. Is almond milk recommended?
Almond milk is moderately high in potassium. Rice milk is recommended due to lowest phosphorus and potassium among the milk substitutes.
25. Protein recommendations for pre-dialysis patients looks high too. Our guidelines are 0.8-1.0g/kg until the patient is on dialysis and have increased needs due to losses through dialysis.
Recommendations vary depending on the source. Older guidelines recommended more severe protein restrictions, but current literature suggests that protein restriction artificially increases eGFR but doesn't preserve kidney function.
26. If using creatinine based equations to estimate GFR, how do you interpret it in patients with only one kidney?
No change. Clinical implications of eGFR are the same whether the filtration capacity is performed by one kidney or two.
27. Which calculation do you recommend to calculate eGFR?
CKD-EPI is considered to be best, although all methods have some limitations.
28. Can the eGFR improve and how can we promote this?
CKD is irreversible but progression can be slowed with good control of hypertension, diabetes and other co-morbid conditions.
Speaker: Alexis Chettiar RN, MSN, ACNP-BC, PhD
Diabetic Kidney Disease: Prevention, Detection and Treatment
Webinar Description: Alexis Chettiar, ACNP-BC, PhD(c) discusses prevention, detection and treatment of diabetic kidney disease (DKD). DKD is one of the most common complications of diabetes and is the leading cause of end-stage renal disease. Management of DKD is a multifaceted approach inclusive of glycemic and hypertension management along with dietary modifications.
Speaker: Simon Heller, BA, DM, FRCP
The Challenge of Hypoglycaemia in Diabetes: Risks, Consequences and Management
Webinar Description: Hypoglycemia is a serious, acute complication of diabetes, and the occurrence of hypoglycemia is linked to increased morbidity, mortality, and cost. Hypoglycemia and the fear of hypoglycemia by patients and healthcare providers are primary barriers to reaching optimal glycemic control, and minimizing hypoglycemia is thought to increase adherence and satisfaction with treatment regimens. Simon Heller, BA, DM, FRCP discusses hypoglycemia, fear of hypoglycemia, and related treatment strategies.