WEBVTT 1 00:00:10.000 --> 00:00:15.400 Hi welcome. You today's webinar on diabetes and renal and impairment. 2 00:00:15.400 --> 00:00:19.900 Let's understand the risk. I'm not Audrey. I'm a registered company as 3 00:00:19.900 --> 00:00:24.300 a register and employers register to donate General Hospital. Before we drove 4 00:00:24.300 --> 00:00:27.500 deep into the topic. Just to give you a brief outline of 5 00:00:27.500 --> 00:00:32.800 what is to come about in today's webinar. This hosted by a 6 00:00:32.800 --> 00:00:37.400 similar on the collaboration with varsity So the outline I'm going to 7 00:00:37.400 --> 00:00:42.500 explain in brief right now. Introduction and epidemiology risk factors pathophysiology of 8 00:00:42.500 --> 00:00:47.700 that. Properties stages, normal kidney functions, greeting method, and diagnosis, management 9 00:00:47.700 --> 00:00:50.900 and prevention. That is what we're going to talk about today before 10 00:00:50.900 --> 00:00:56.000 July, for the topic. So, in order to introduce first, 11 00:00:56.000 --> 00:01:01.200 since this platform is from India, like to give a brief 12 00:01:01.200 --> 00:01:06.200 destruction, a distribution. Sorry. Yeah. Just scripture of the currency in India. 13 00:01:06.200 --> 00:01:10.400 So India is increased Board of chronic disease like hypertension and diabetes 14 00:01:10.400 --> 00:01:14.200 and so does Bangladesh. Ah India has also one of the largest 15 00:01:14.200 --> 00:01:20.600 number of people with diabetes around 6 3, 1. 3. In 16 00:01:20.600 --> 00:01:24.700 fact, Bangladesh is not too behind its second in that list with 17 00:01:24.700 --> 00:01:30.200 13.1 million diabetic publishing. And India has a prevalence of 9.2% 18 00:01:30.200 --> 00:01:35.100 in adults, for diabetes and Bangladesh has 11.3%, which is even higher 19 00:01:35.100 --> 00:01:39.900 than India. Now, 25 to 40% of these develop and Stage, we 20 00:01:39.900 --> 00:01:44.400 know disease. So today's topic is of omnipotent importance for us because 21 00:01:44.400 --> 00:01:48.400 we know that the diabetic effort is one of the leading causes 22 00:01:48.400 --> 00:01:53.400 of mortality in diabetic. Patients both type 1 and type 2, diabetes 23 00:01:53.400 --> 00:01:56.900 can cause Diaries but more. So in the type 2 diabetes population, 24 00:01:56.900 --> 00:02:01.200 what are the features of diving their property is increasing urinary albumin, 25 00:02:01.200 --> 00:02:05.100 expression, Rising BB and declining renal function. These are the features of 26 00:02:05.100 --> 00:02:10.800 diving networking. Well, so certain risk factors are involved that interplay 27 00:02:10.800 --> 00:02:16.000 between the pathogenesis of diabetic nephropathy. These genetic some 28 00:02:16.000 --> 00:02:20.100 are the genetic factors. Now people that a person with the family 29 00:02:20.100 --> 00:02:23.700 history of diabetes, methodology is more likely to develop it as well. 30 00:02:23.700 --> 00:02:28.800 Now, these could be contributed to some chromosome abnormalities. In the Americans, 31 00:02:28.800 --> 00:02:35.700 the ethnic minorities like the African-Americans the American Indians, 32 00:02:35.700 --> 00:02:40.200 as well as the, our Southeast Asians are more prone to developing 33 00:02:40.200 --> 00:02:44.600 their property because of our chromosomal abnormalities are now jeans. of course, 34 00:02:44.600 --> 00:02:49.600 inadequate glucose control is one of the Mainstay in one 35 00:02:49.600 --> 00:02:54.700 of the factors major factors in using the risk of Nefertiti 36 00:02:54.700 --> 00:02:59.000 high blood pressure, We know that high blood pressure is long with 37 00:02:59.000 --> 00:03:04.300 increased blood glucose, these two of them main contributing factors that lead 38 00:03:04.300 --> 00:03:09.800 to diving their football. Team usually secondary hypertension can occur can 39 00:03:09.800 --> 00:03:17.100 cause kidney disease. What is a sociable progressional nevermind you 40 00:03:17.100 --> 00:03:22.400 know that lipid. A phenotype is altered in when there's a progression 41 00:03:22.400 --> 00:03:25.700 of diabetic property and lipids. Could also play a key role in 42 00:03:25.700 --> 00:03:30.900 the development and progression of neighboring nephropathy. Smoking is also another risk 43 00:03:30.900 --> 00:03:35.500 factor the main anthropology between smoke smoking and diabetic. Everybody is not 44 00:03:35.500 --> 00:03:41.800 yet elucidated but we know that smoking can increase insulin 45 00:03:41.800 --> 00:03:44.500 resistance and that could be one of the contributing factors for the 46 00:03:44.500 --> 00:03:49.500 development of diving effort. But he Longstanding, diabetes, increased duration 47 00:03:49.500 --> 00:03:54.200 of diabetes can also increase the risk for developing their property. Pregnancy 48 00:03:54.200 --> 00:03:58.200 is a physiological response. Usually there's a rise in GFR, which returns 49 00:03:58.200 --> 00:04:03.200 to normal after delivery, but hypertension movement, who are pregnant, there are 50 00:04:03.200 --> 00:04:07.700 more at risk of developing nephew. So, these are some of the 51 00:04:07.700 --> 00:04:13.400 factors contributing to progression of diabetic Nefertiti. and, Here 52 00:04:13.400 --> 00:04:16.200 I can, I have already explained. I'm just going to briefly outline 53 00:04:16.200 --> 00:04:21.700 the systemic blood pressure hypertension proteinuria, glycemic control hyperlipidemia, 54 00:04:21.700 --> 00:04:26.900 Ace identity, smoking dietary 55 00:04:26.900 --> 00:04:30.700 protein intake, obesity. I'm going to explain more in detail later but 56 00:04:30.700 --> 00:04:35.300 these are major factors contributing to progression of diabetic. So, when we 57 00:04:35.300 --> 00:04:39.200 do want to talk about the pathophysiology time dignity, we know there's 58 00:04:39.200 --> 00:04:43.100 a constant in the play between hemodynamic as well as metabolic factors. 59 00:04:43.100 --> 00:04:48.200 So, these two factors are the most important contributing factors which contributed, 60 00:04:48.200 --> 00:04:52.300 the pathophysiology of diabetic energy. So the you know, hemodynamic factors are 61 00:04:52.300 --> 00:04:57.500 increased systemic and interglobular pressure Activation of vasoactive 62 00:04:57.500 --> 00:05:01.800 hormones, particularly we have to mention the rendered engine system, and the 63 00:05:01.800 --> 00:05:06.500 engineering system. So these lead to activation of intracellular second messengers, like 64 00:05:06.500 --> 00:05:11.500 protein, kinase, C, map, kinase NK, Alpha bin, as a nuclear, transcription 65 00:05:11.500 --> 00:05:16.500 factors also growth factors can be activated, like, gross, creative, 66 00:05:16.500 --> 00:05:21.900 cytokines tgfb permeability and growth factor and 67 00:05:21.900 --> 00:05:26.900 Vascular, growth factors. These are the hemodynamic factors that can cause diabetic 68 00:05:26.900 --> 00:05:32.100 for protein. on the metabolic factors pretty much common in just 69 00:05:32.100 --> 00:05:37.300 not targeting fertility but also neuropathy and regular that's explains why there's 70 00:05:37.300 --> 00:05:41.700 a higher incidence and higher prevalence of diabetic neuropathy as well as 71 00:05:42.600 --> 00:05:47.500 Red doors were diving upper-cutting. So the metabolic metabolic factors involve activation 72 00:05:47.500 --> 00:05:52.300 of glucose-dependent Pathways inside the kidney, which can lead to enhanced oxidative, 73 00:05:52.300 --> 00:05:57.700 stress renal, polyol formation and sorbitol formation as 74 00:05:57.700 --> 00:06:03.100 well as accumulation Advanced glycation and products. These are very important at 75 00:06:03.100 --> 00:06:08.000 the mechanisms between that lay the foundation for the pathophysiology of diving 76 00:06:08.000 --> 00:06:12.200 efficiency. So an activation of these both hemodynamic, as well as metabolic 77 00:06:12.200 --> 00:06:17.700 factors result in increase, albumin, permeability and accumulation of external 78 00:06:17.700 --> 00:06:22.800 metrics, leading to increase, proteinuria, lawyers, and finally, 79 00:06:22.800 --> 00:06:28.200 to Shield fibrosis. So, the Mainstay is the proteinuria, 80 00:06:28.200 --> 00:06:33.800 glorious. And two ways to wear interstitial fibrosis. So, 81 00:06:33.800 --> 00:06:37.000 if you look into the natural history of kidney disease, it processes 82 00:06:37.000 --> 00:06:40.100 to 5 predictable stages, which I'm going to explain more in detail. 83 00:06:40.100 --> 00:06:45.100 Stage 1 is titled as early hyperfunction. Stage 2 is glomerular 84 00:06:45.100 --> 00:06:50.500 region with clinical finding stage 37 stage. Stage 85 00:06:50.500 --> 00:06:54.600 4 is over dieting. Their property Stage 5 is in stage renal 86 00:06:54.600 --> 00:07:00.000 various. So these are the natural progression that diving for the force. 87 00:07:01.600 --> 00:07:06.300 The stage one is titled as early high performance characters by hyperfunction 88 00:07:06.300 --> 00:07:11.300 hyperfunction usually results from Global basement membrane thickening, which can 89 00:07:11.300 --> 00:07:15.700 result in an increase in charge of pressure, which causes this High 90 00:07:15.700 --> 00:07:19.100 professional. But this High profession can easily be reversed by blood sugar 91 00:07:19.100 --> 00:07:24.400 control, such as insulin treatment and there are structural changes like hyperplasia 92 00:07:24.400 --> 00:07:29.100 and hypertrophy of nephrons kidney sizes increase. Now they interesting thing here 93 00:07:29.100 --> 00:07:33.200 is the GFS increased in stage 1 and 2, but as we 94 00:07:33.200 --> 00:07:37.400 progress for the GFR decreases, the blood pressure is still normal in 95 00:07:37.400 --> 00:07:41.000 the first two stages, but then it starts increasing albumin and screen 96 00:07:41.000 --> 00:07:44.700 is increased. And by physical activity probation test is also increase. So 97 00:07:44.700 --> 00:07:48.100 I'm going to expression is normally also increased and all by publication 98 00:07:48.100 --> 00:07:53.200 is also increased like a mentioned. The state is reversible by blood 99 00:07:53.200 --> 00:07:58.200 sugar control. Stage 2 consists of glomerular, reason, without clinical findings. 100 00:07:58.200 --> 00:08:02.400 It takes years to develop, there are structural changes. Like, I mentioned, 101 00:08:02.400 --> 00:08:06.700 they increased signals of basement membrane, the GFI is increased on normal. 102 00:08:06.700 --> 00:08:11.800 So here we have a normal as well as increased GFR. The 103 00:08:11.800 --> 00:08:16.100 blood pressure is within normal, still animal expression is more of the 104 00:08:16.100 --> 00:08:20.700 patients are within normal and exercise. Abnormal after years, this stage is 105 00:08:20.700 --> 00:08:23.200 also reversible by blood sugar control. The first two things. Like a 106 00:08:23.200 --> 00:08:27.800 mentioned can be reversed if you have adequate blood sugar control, The 107 00:08:27.800 --> 00:08:32.200 stage 3 is where things get more complicated and it starts to 108 00:08:32.200 --> 00:08:37.300 get into the reversible phase, the incipient stage where the structural changes 109 00:08:37.300 --> 00:08:42.600 are not well studied GFR still increased the blood pressures increase here 110 00:08:42.600 --> 00:08:46.300 from now on as well as the albumin excretion is increased by 111 00:08:46.300 --> 00:08:50.900 25 microgram per minute each year. The stage 4 is where we 112 00:08:50.900 --> 00:08:55.600 have over diabetic nephropathy, which is called characteristics were pronounced continuous. So 113 00:08:55.600 --> 00:08:58.700 we have the highest great opportunity here in this stage and the 114 00:08:58.700 --> 00:09:04.200 structural changes, there's diffuse a lot of curses and highnesses of arterial 115 00:09:04.200 --> 00:09:08.300 walls, the GFS decreased from now on now we can see the 116 00:09:08.300 --> 00:09:13.700 GFS to solid starting to decline that expression Progressive opportunities, 117 00:09:13.700 --> 00:09:18.700 increased albumin, excretion blood pressure is increased. Or interesting Factor 118 00:09:18.700 --> 00:09:22.400 over here, is the antihypertensive treatment retards the progression. So we should 119 00:09:22.400 --> 00:09:28.000 aim for BPO 140 by 85 to 90 in this stage. And 120 00:09:28.000 --> 00:09:32.100 the final stage is end stage renal failure which is characterized by 121 00:09:32.100 --> 00:09:36.400 Romero closure the GFS less than 15 ml per minute. The blood 122 00:09:36.400 --> 00:09:39.100 pressure is high. This is a stage where we have to consider 123 00:09:39.100 --> 00:09:44.300 hemodialysis and peritoneal dialysis and possible renal transplant. We 124 00:09:44.300 --> 00:09:49.300 know replacement therapy, So corresponding GFS to 125 00:09:49.300 --> 00:09:52.500 the stages, we can see the stage one, the GFR is greater 126 00:09:52.500 --> 00:09:56.100 than or equal to 19 milliliter per minute. Stage 2 is from 127 00:09:56.100 --> 00:10:00.500 89 to 60 stage 3, 59 to 30 stage, 429 to 15 128 00:10:00.500 --> 00:10:05.600 and Stage 5, less than 15 millimeter per minute. So, the normal 129 00:10:05.600 --> 00:10:08.600 kidney function, what is the function of the actual kidney, the functional 130 00:10:08.600 --> 00:10:12.400 unit, we know is the nephron. Its function is to filter the 131 00:10:12.400 --> 00:10:16.900 blood into the tubules which are very thin false walls, normally materials 132 00:10:16.900 --> 00:10:20.700 that body needs flow back and waist are thrown back across these 133 00:10:20.700 --> 00:10:25.200 walls. Most important is glucose which is reabsorbed back completely. So this 134 00:10:25.200 --> 00:10:29.200 is a normal process of filtration and reabsorption where it's important for 135 00:10:29.200 --> 00:10:34.400 us. At the normal. Waste products are filtered and glucose is reabsorbed 136 00:10:34.400 --> 00:10:39.600 in the kidneys. Mostly in the proximal communicative use The structure 137 00:10:39.600 --> 00:10:43.300 of the Nephron, it's important note here is this is where the 138 00:10:43.300 --> 00:10:46.800 major changes take place in the global basement membrane, the messenger cells. 139 00:10:48.100 --> 00:10:53.000 And the this is where where most of the and the global 140 00:10:53.000 --> 00:10:57.800 and Realtors sells, this is where most of the pathophysiology of diving 141 00:10:57.800 --> 00:11:03.200 their credit takes place. Like I mentioned before, So, how would 142 00:11:03.200 --> 00:11:06.900 you categories between the normal was declining function of the kidney? Normal 143 00:11:06.900 --> 00:11:11.100 kidney function is to remove nitrogenous waste products. When like I mentioned 144 00:11:11.100 --> 00:11:15.700 the waste products, is filtered out by the kidney, the fluid, and 145 00:11:15.700 --> 00:11:19.400 electrolyte and acid-base balance is maintained by the kidney. The blood pressure 146 00:11:19.400 --> 00:11:23.100 control through in any engine tension system is maintained by the kidney 147 00:11:23.100 --> 00:11:28.000 this expression of certain drugs. Very importantly, there's production of editor providing 148 00:11:28.000 --> 00:11:30.900 which you can see in the later stages of ends CKD and 149 00:11:30.900 --> 00:11:34.000 end stage. We know this is declining and there's a formation of 150 00:11:34.000 --> 00:11:39.200 125. Dehydration dehydration vitamin D, which also declines as the stages 151 00:11:39.200 --> 00:11:44.100 of nephropathy progresses. So when does it decline when you can you 152 00:11:44.100 --> 00:11:49.300 notice a decline when there's increased serum, blood urea, nitrogen and creatinine 153 00:11:49.300 --> 00:11:53.800 when there is fluid and sodium retention and there's increased serum, potassium 154 00:11:53.800 --> 00:11:57.800 and metabolic acidosis. One of the key features of chronic kidney disease 155 00:11:57.800 --> 00:12:04.500 or diameter for diabetic kidney disease. Is renal 156 00:12:04.500 --> 00:12:09.000 failure, which can result in metabolic acids as well as increase potassium. 157 00:12:09.800 --> 00:12:13.100 and as well as when we start treatment with asymptotes, what we 158 00:12:13.100 --> 00:12:17.600 have to monitor, whether the potassium and creating levels increase in, Hypertension 159 00:12:17.600 --> 00:12:21.600 also could be a one of the factors which could contribute to 160 00:12:21.600 --> 00:12:25.200 declining renal function, or duration of drug activity. There's a decreased production 161 00:12:25.200 --> 00:12:29.000 of Heritage portal and I mentioned and this could lead to anemia. 162 00:12:29.000 --> 00:12:34.300 There's a decrease calcium absorption. So, What 163 00:12:34.300 --> 00:12:37.800 is the clinical evidence of diabetic property? The earliest biochemistry, what we 164 00:12:37.800 --> 00:12:41.800 want to detect if we can figure out is the albuminuria, which 165 00:12:41.800 --> 00:12:46.500 I'll explain more without interventions. 80% of type 1 diabetes, have uranium 166 00:12:46.500 --> 00:12:50.300 expiration increased a 10 to 20% per year to over an effort 167 00:12:50.300 --> 00:12:53.200 about your period of 6, to 15 years. So it takes time 168 00:12:53.200 --> 00:12:56.900 for a type 1, diabetic patient to developing their property, usually in 169 00:12:56.900 --> 00:13:00.100 the range of 6 to 15 years, as a post to a 170 00:13:00.100 --> 00:13:05.700 type 2 diabetes patient which could occur Very probably or start 171 00:13:05.700 --> 00:13:10.800 at the diagnosis of diabetes. So, once over 30 occurs with or 172 00:13:10.800 --> 00:13:14.100 without interventions, gear for Falls, over a period of several years, like 173 00:13:14.100 --> 00:13:16.500 I mentioned, this is a stage where it's it was reversible damage 174 00:13:16.500 --> 00:13:21.800 to the kidney, eventually 50% of type 1, diabetes individuals, develop earring, 175 00:13:21.800 --> 00:13:26.900 within 10 years and 75% of 1. Diabetes individuals develop ESI by 176 00:13:26.900 --> 00:13:31.000 20 years old. Almost three, fourth of the deed. One diabetic population 177 00:13:31.000 --> 00:13:36.000 will start by 20 years. Now, why is it so important? 178 00:13:36.000 --> 00:13:41.100 Because the cost attributed to ESRD treatment is extremely high. 179 00:13:42.000 --> 00:13:46.900 Like in UK average yearly expenditure is about 12 to 14 billion 180 00:13:46.900 --> 00:13:51.900 dollars that have been spent on just due to complications 181 00:13:51.900 --> 00:13:57.100 related to diabetes treatment, diabetes complications. So, what do we screen? And 182 00:13:57.100 --> 00:13:59.500 when do we screen? This is very much important for us. So 183 00:13:59.500 --> 00:14:02.700 type 2, diabetes patients should be screened for micro when you're at 184 00:14:02.700 --> 00:14:07.600 the time of diagnosis. So like I mentioned it could occur initially 185 00:14:07.600 --> 00:14:11.500 interactive diabetes patients as 7% of them will already have developed. So 186 00:14:11.500 --> 00:14:15.000 we should screen type 2 diabetic specials as soon as he is 187 00:14:15.000 --> 00:14:19.100 diagnosed with type 2 diabetes. The first screening for type 1, diabetes 188 00:14:19.100 --> 00:14:21.700 is five years like I mentioned it takes time 1615 years to 189 00:14:21.700 --> 00:14:26.700 developing type 1. Diabetes patients. What if 190 00:14:26.700 --> 00:14:29.800 the glycemic control is for, it should be performed one year after 191 00:14:29.800 --> 00:14:35.100 diagnosed. So time to diabetes initially and annually type, 192 00:14:35.100 --> 00:14:40.500 one diabetes. After five years and annually should be screen for Albany 193 00:14:40.500 --> 00:14:45.400 New Year. And the absence of microbial screening should be repeated. Annually 194 00:14:45.400 --> 00:14:48.600 for both type 1 and type 2 diabetes patients. Now, the gold 195 00:14:48.600 --> 00:14:52.400 standard, Ada recommended method is to measure albumin in a spot urine 196 00:14:52.400 --> 00:14:56.300 sample either morning or a random one. So the results are expressed 197 00:14:56.300 --> 00:15:01.300 as urinary, albumin, concentration, milligram per liter or as urinary ACR, 198 00:15:01.300 --> 00:15:04.800 which I've been increased retaining ratio which can imagine in milligram per 199 00:15:04.800 --> 00:15:10.100 mil. So there are some alternate results to the urinary, albumin 200 00:15:10.100 --> 00:15:14.600 expression. Like I mentioned now, when do we use these Alternatives? Alternatives 201 00:15:14.600 --> 00:15:17.600 are used because there are some fall for false positive results that 202 00:15:17.600 --> 00:15:22.600 could occur in UA results, which could be due to unite 203 00:15:22.600 --> 00:15:27.700 infections. Men's pronounced pronoun hyperglycemia 204 00:15:27.700 --> 00:15:32.700 even Advanced cardiovascular disease can cause false positive results in your 205 00:15:32.700 --> 00:15:37.400 area. So you can use some Alternatives here. Like semiconductor logistic measure 206 00:15:37.400 --> 00:15:42.500 of Albany area, qualitative stigma method for proteinuria 207 00:15:42.500 --> 00:15:47.600 quantitative measurement approaching and urine spots sample. And also 24-hour urine protein 208 00:15:47.600 --> 00:15:52.500 collection, we can perform these tests also. But these are more less 209 00:15:52.500 --> 00:15:57.800 selective and less sensitive. And as well as these are more Combos. 210 00:15:57.800 --> 00:16:03.100 And to perform in regular cleaning settings, So, Daniel 211 00:16:03.100 --> 00:16:07.000 checkup, what should be included? There should be checked for protein and 212 00:16:07.000 --> 00:16:11.500 fasting urine sample using a urine dipstick. If it is positive, then 213 00:16:11.500 --> 00:16:15.000 the person should be checked for Unique tract infection and allow urine 214 00:16:15.000 --> 00:16:19.300 PCR like a protein, creatinine ratio if it is negative, you ran 215 00:16:19.300 --> 00:16:21.400 out of women should be checked using a lab SE, like an 216 00:16:21.400 --> 00:16:25.700 animal in Creative in ratio, if PCR or ACR elevated test, should 217 00:16:25.700 --> 00:16:29.100 be repeated twice and next four to six months. Now here, what's 218 00:16:29.100 --> 00:16:33.800 important is that if two samples are positive in six months, then 219 00:16:33.800 --> 00:16:38.300 we can confirm this is okay. So I didn't and the screening 220 00:16:38.300 --> 00:16:42.000 is positive for my route. When you So how do we Define 221 00:16:42.000 --> 00:16:44.800 the property based on albuminuria? This is very much important for us 222 00:16:44.800 --> 00:16:49.900 depending on the urine specimens, these are overnight 223 00:16:49.900 --> 00:16:54.900 collection. The micromania is from 20 to 199 microamps per 224 00:16:54.900 --> 00:16:59.000 minute in. The clinical Equity is greater than 200. Well, the 24-hour 225 00:16:59.000 --> 00:17:03.700 urine collection, it should be in for microbial. Vinegar is 32 to 226 00:17:03.700 --> 00:17:08.600 299 milligram per day, but clinical effort is greater than or equal 227 00:17:08.600 --> 00:17:13.200 to 300 milligrams per day album in Constitution. If you measure the 228 00:17:13.200 --> 00:17:18.200 microwave Engineers 20 to 300 milligrams per liter for clinical everybody 229 00:17:18.200 --> 00:17:23.300 is greater than 300 million ratio in if you mess 230 00:17:23.300 --> 00:17:26.600 with the ACR in Europe it's in the case of males is 231 00:17:26.600 --> 00:17:31.000 2.5 to 30 million more and in case of females is 3.5 232 00:17:31.000 --> 00:17:36.400 to 30 milligram per minute, in clinical nephropathy 233 00:17:36.400 --> 00:17:41.500 is great in female's lesson greater than 30 milligrams per millimole, And 234 00:17:41.500 --> 00:17:46.600 in female's of greater than 30 million per minute in 235 00:17:46.600 --> 00:17:51.600 Asia, USA, if you follow both 30, males and female 32, 300 236 00:17:51.600 --> 00:17:56.900 million per gram and also in Clinton. So, 237 00:17:56.900 --> 00:18:00.400 these markers are very much important for us. If he went to 238 00:18:00.400 --> 00:18:05.400 distinguish microbial from clean government, But of course, the 239 00:18:05.400 --> 00:18:09.800 diagnosis, if you want to come from diabetic, renal biopsy is the 240 00:18:09.800 --> 00:18:14.700 gold standard method, but we know it's a very difficult process and 241 00:18:14.700 --> 00:18:19.200 it's an invasive procedure. So it can also be deferred when we 242 00:18:19.200 --> 00:18:23.500 assume the diagnosis of diabetic. Diabetic nephropathy in the context of macro 243 00:18:23.500 --> 00:18:28.100 Albania, Greater than 300 milligram per 24 hours that is developed progressively. 244 00:18:28.100 --> 00:18:31.700 So there's no need to perform a renal biopsy. We have confirmation 245 00:18:31.700 --> 00:18:36.700 microbial, 330 to 300 milligrams or 24 hours with regional 246 00:18:36.700 --> 00:18:41.100 Petty. Like I mentioned, the diabetic property is also associated with region 247 00:18:41.100 --> 00:18:44.400 of these specialty in type 1 diabetic patients. They have a high 248 00:18:44.400 --> 00:18:49.400 incidence of vegetables as well as neuropathy micro Albania and patients 249 00:18:49.400 --> 00:18:53.300 with diabetes for more than 10 years. So then we can defer 250 00:18:53.300 --> 00:18:57.900 the real biopsy. So the management is very much important for us, 251 00:18:57.900 --> 00:19:03.700 the presence of microalb started. So 252 00:19:03.700 --> 00:19:06.900 what do we you? What is the first line of treatment that 253 00:19:06.900 --> 00:19:12.100 we give you should use an AC inhibitor because it's 254 00:19:12.100 --> 00:19:16.600 in Social, that microbial indicates increased pressure in the kidney. So you 255 00:19:16.600 --> 00:19:21.000 there's several trials with ACE inhibitors as well as arbs. Both are 256 00:19:21.000 --> 00:19:25.600 clinically effective in reducing microbial early in the course of the disease. 257 00:19:25.600 --> 00:19:30.900 I'll explain more in detail a bit later. So the 258 00:19:30.900 --> 00:19:35.900 target BP that should be managed should be 130 by 80 SB. 259 00:19:35.900 --> 00:19:40.600 Once you should be less than what 6.5% now, here is very 260 00:19:40.600 --> 00:19:43.900 important for us. Specially in our countries is we should reduce the 261 00:19:43.900 --> 00:19:48.800 protein in diet to point, eight gram per kilogram body weight, for 262 00:19:48.800 --> 00:19:53.500 early stages of property. And one to one point, two gram per 263 00:19:53.500 --> 00:19:56.500 kilogram per day. Now here, what's important for For us as we 264 00:19:56.500 --> 00:20:01.200 increase the protein content for those on dialysis because they have increased 265 00:20:01.200 --> 00:20:05.200 protein and energy, malnutrition and protein energy wasting, so it's important for 266 00:20:05.200 --> 00:20:08.600 them to give them aside your high protein. But in the early 267 00:20:08.600 --> 00:20:13.300 stages, we should reduce from the protein in the diet. Now, what's 268 00:20:13.300 --> 00:20:17.000 important for us is we have to know, actually, how much protein 269 00:20:17.000 --> 00:20:20.700 are we taking? Because in Western countries there are more prone to 270 00:20:20.700 --> 00:20:24.000 take more proteins but it's in South Asian countries. We are more 271 00:20:24.000 --> 00:20:28.800 prone to consuming carbohydrates and protein. So it's very important for us 272 00:20:28.800 --> 00:20:33.100 to calculate our proteins before we dwell into the protein restriction, right? 273 00:20:33.100 --> 00:20:36.200 And here, the reduction in protein is in the second class called, 274 00:20:36.200 --> 00:20:39.700 in more than the first class proteins. So, vegetable protein should be 275 00:20:39.700 --> 00:20:44.800 restricted in these patients lipid management and smoking. Cessation has been through 276 00:20:44.800 --> 00:20:49.100 his very helpful for us. So, these are some studies that have 277 00:20:49.100 --> 00:20:54.800 been done with Airbnb and Asian videos in reducing. Dividing 278 00:20:54.800 --> 00:20:57.100 their, for protein risk, as well as reducing protein, as well as 279 00:20:57.100 --> 00:21:00.300 microbial here. We can see with the idea and T renal, and 280 00:21:00.300 --> 00:21:04.800 Marvel trials. With various arbs, like areas are down, losartan, and as 281 00:21:04.800 --> 00:21:07.600 well as well. Certain here, we can see almost up to 50% 282 00:21:07.600 --> 00:21:10.900 reduction in protein here. So most important for us is to start 283 00:21:10.900 --> 00:21:16.800 a centimeter or arbs when diagnosed with diabetic effort. But now 284 00:21:16.800 --> 00:21:21.400 the question is, should be start as Inhibitors as a prevention or 285 00:21:21.400 --> 00:21:25.100 diabetic for. But, you know, we shouldn't because it's not recommended if 286 00:21:25.100 --> 00:21:29.600 the patient does not have high blood pressure. If the patient does 287 00:21:29.600 --> 00:21:33.100 not have a increase urinary ACR, if the patient does not have 288 00:21:33.100 --> 00:21:38.100 microbial Community here, we should not start a simulator or arbs 289 00:21:38.100 --> 00:21:41.600 for the prevention of limiting effort. That's very important for us, you 290 00:21:41.600 --> 00:21:46.400 know? It. So when we look into the different stages on everybody, 291 00:21:46.400 --> 00:21:49.900 there are different management strategies that we can employ here. So stage 292 00:21:49.900 --> 00:21:53.200 one, which I mentioned is no proteinuria or the early high performance 293 00:21:53.200 --> 00:21:58.400 stage lifestyle modification is very much important for us died exercises. 294 00:21:58.400 --> 00:22:03.000 Very important dietary control or carbohydrate and fat and salt. Restriction is 295 00:22:03.000 --> 00:22:06.000 very much important so that we can balance our diabetes as well 296 00:22:06.000 --> 00:22:11.000 as blood pressure, exercise, and smoking Sensational. Very much important 297 00:22:11.000 --> 00:22:16.200 for us. And this case 150 minutes or exercise 298 00:22:16.200 --> 00:22:21.200 moderate exercise almost five days a week or 75 minutes of 299 00:22:21.200 --> 00:22:25.300 intensive exercises. Very much important for us. When the glycemic control, we 300 00:22:25.300 --> 00:22:30.300 should Target our sb1 see less than 7% and 6.5 301 00:22:30.300 --> 00:22:44.400 to 7% as improved glycemic control stores. The 302 00:22:44.400 --> 00:22:49.600 BP should be mentioned below, 13880 lipids statins. If Target levels are 303 00:22:49.600 --> 00:22:54.600 not achieved, astonishing should be prescribed. Here, I must mention that atorvastatin 304 00:22:54.600 --> 00:22:59.200 can be given to these patients who have advanced kidney disease, wherever 305 00:22:59.200 --> 00:23:04.200 them are still in. Stage 2 microbial. We have to monitor 306 00:23:04.200 --> 00:23:08.300 the urinary proteins and the 24 hours. You create any clearance, add 307 00:23:08.300 --> 00:23:13.300 an Ace inhibitor or an ARB current guidelines, recommend that normal tension 308 00:23:13.300 --> 00:23:18.600 with microalbumin, with an Ace inhibitor. So if there's presence 309 00:23:18.600 --> 00:23:21.900 of microbial, when you're then only you should give an Ace inhibitor. 310 00:23:21.900 --> 00:23:26.900 Now, the dose of a centimeters very important because we shouldn't 311 00:23:26.900 --> 00:23:29.600 start with very high doses. We just start with low dose and 312 00:23:29.600 --> 00:23:34.700 increase because we know that as Inhibitors are on to cause 313 00:23:34.700 --> 00:23:39.100 hyperkalemia as well as can increase the Creatine level. So we should 314 00:23:39.100 --> 00:23:43.400 monitor the creatinine levels as we should monitor, the production levels when 315 00:23:43.400 --> 00:23:48.500 we start commence the patients on asymmetry Airbnb therapy, Stage 316 00:23:48.500 --> 00:23:52.800 3, proteinuria, all of the Baba I mentioned before, plus how that 317 00:23:52.800 --> 00:23:56.000 BP aim is reduced to one training by 17 and the low 318 00:23:56.000 --> 00:24:01.000 protein diet is applicable. Now stage 4 declining, kidney function, prepare 319 00:24:01.000 --> 00:24:03.800 for dialysis or Windows transplant. This is the point of no return 320 00:24:03.800 --> 00:24:09.100 where we should prepare the patient for decreasing the mortality 321 00:24:09.100 --> 00:24:14.400 in dividing their property Stage 5 years Audi, dialysis hemo 322 00:24:14.400 --> 00:24:19.500 or peritoneal dialysis, and the finally Transportation kidney Opera kidney Transportation 323 00:24:19.500 --> 00:24:23.500 can be taken into conservation, so we can Target what diving of 324 00:24:23.500 --> 00:24:29.300 property as well as diabetes itself. It. So, like I mentioned this 325 00:24:29.300 --> 00:24:33.600 was some of the therapies that can be used for diabetic nephropathy. 326 00:24:33.600 --> 00:24:39.200 So what can what are the anti-diabetic medications that are oral hypoglycemic? 327 00:24:39.200 --> 00:24:44.200 Are oral anti-diabetic medication, that can Be used for slowing down the 328 00:24:44.200 --> 00:24:48.100 progression of diabetic property. So these are some of the studies that 329 00:24:48.100 --> 00:24:53.000 have been done with SGD 2 Inhibitors, the emperor kidney, study the 330 00:24:53.000 --> 00:24:57.300 kidney disease progression or cardiovascular death here. We can see that the 331 00:24:57.300 --> 00:25:01.300 absolute risk of kidney disease. Progression are dying from heart disease. In 332 00:25:01.300 --> 00:25:06.700 the emperor kidney, participants is reduced by 3.8% by taking so 333 00:25:06.700 --> 00:25:09.300 here. What is very much important for us in the early stages 334 00:25:09.300 --> 00:25:13.300 of diabetic effort at the stage 1 and Stage 2? If we 335 00:25:13.300 --> 00:25:17.500 give sg2 Inhibitors can actually be the GFR. So that's very important 336 00:25:17.500 --> 00:25:20.700 for us. Not these actually are doing. He does not just limited 337 00:25:20.700 --> 00:25:24.900 just to the public laws in, but even with the gradients with 338 00:25:24.900 --> 00:25:29.000 the, we can see with chronicle Frozen, as well as the darker 339 00:25:29.000 --> 00:25:33.800 kidney trails and we can see similar results in kidney progression, which 340 00:25:33.800 --> 00:25:37.400 can reduce the risk of kidney disease progression. And that is why 341 00:25:37.400 --> 00:25:43.000 now the Ada and the AAC, as well as the European. And 342 00:25:43.000 --> 00:25:48.100 even the European cardiac cardiac Society has also mentioned about prescribing. 343 00:25:49.800 --> 00:25:54.200 SGD to Inhibitors as a first line therapy. For those patients that 344 00:25:54.200 --> 00:25:58.900 have at once the kidney disease, as well as advanced audio scholar 345 00:25:58.900 --> 00:26:05.700 cardiovascular disease. Only if they are not already then even people and 346 00:26:05.700 --> 00:26:08.300 Agnes can also be given. But what we have to take into 347 00:26:08.300 --> 00:26:12.600 consideration that if the egfr is less than 20, we cannot give 348 00:26:12.600 --> 00:26:15.700 empathy flows in or any other actually doing if it does. So 349 00:26:15.700 --> 00:26:21.700 it is restricted to those less than 20. Other 350 00:26:21.700 --> 00:26:26.800 drugs, like minor record receptor. Antagonist. Also, 351 00:26:26.800 --> 00:26:31.400 very much important and we are seeing the new drug, which is 352 00:26:31.400 --> 00:26:35.500 a thinner row, which can improve here from the trials. We can 353 00:26:35.500 --> 00:26:39.600 see with the Fidelio degree trials or the figure out a degree 354 00:26:39.600 --> 00:26:43.700 trial. Here we can see that finer learns the kidney outcomes, including 355 00:26:43.700 --> 00:26:47.200 reducing the risk of and States we know disease. And it's also 356 00:26:47.200 --> 00:26:50.000 well tolerated in patients with security and tied to the industry. So 357 00:26:50.000 --> 00:26:53.300 we have many, many treatment options available provided that we start the 358 00:26:53.300 --> 00:26:57.500 treatment early on in the stage of the disease and so that 359 00:26:57.500 --> 00:27:02.600 we can reverse the complications that can arise due to diabetic 360 00:27:02.600 --> 00:27:07.100 nephropathy. So here we mention about blood glucose reduction, here we mentioned 361 00:27:07.100 --> 00:27:11.400 about blood pressure reduction, we mention about the role of ACE inhibitors. 362 00:27:11.400 --> 00:27:16.700 We mention about the roast of dietary protein, restriction, salt 363 00:27:16.700 --> 00:27:22.000 restriction. And finally the role of Mineral Water Protocol receptor agonists in 364 00:27:25.500 --> 00:27:30.300 So, what's very important for us? Endocrinologist? Is, we should also refer 365 00:27:30.300 --> 00:27:33.300 the patients to an effort. So, when should we refer to be 366 00:27:33.300 --> 00:27:37.800 refer in all stages of nephropathy or in certain stages, should be 367 00:27:37.800 --> 00:27:42.000 referred. So, we should consider referral when the diabetic patients, have an 368 00:27:42.000 --> 00:27:46.600 egfr of less than 60 millimeter per minute per meter square. If 369 00:27:46.600 --> 00:27:50.200 there's a protein or greater than one gram per 24 hours, and 370 00:27:50.200 --> 00:27:53.200 there's difficult to control hypertension is very much important for us to 371 00:27:53.200 --> 00:27:57.300 refer these patients to the nephrologists at any stage. If the egfr 372 00:27:57.300 --> 00:28:01.700 is less than 13 millimeter per minute per meter Square, we should 373 00:28:01.700 --> 00:28:06.100 refer to an author. Just if there's an unexplained declining, kidney function, 374 00:28:06.100 --> 00:28:10.300 like 15% drop in egfr or what three months, what's important for 375 00:28:10.300 --> 00:28:16.000 us? And what the all the governing bodies recommended 376 00:28:16.000 --> 00:28:19.800 that we shouldn't stop the ACE inhibitors. If there's a southern decline 377 00:28:19.800 --> 00:28:25.900 in kidney functions, like even if there's a 30% decline in egfr, 378 00:28:25.900 --> 00:28:30.400 we shouldn't stop the Asians because of the pronouns benefits of a 379 00:28:30.400 --> 00:28:35.400 significance. But yes, we should look into the backdrop. Whether this job 380 00:28:35.400 --> 00:28:40.600 was due to renal arteries or not. So in that case, it's 381 00:28:40.600 --> 00:28:45.700 content game. Some abnormal findings which are not related to diabetes. 382 00:28:45.700 --> 00:28:50.800 These are Global hyper immature. Particularly continuous present 383 00:28:50.800 --> 00:28:56.000 absence of Albania, without with abnormal creatinine, Resistant hypertension, 384 00:28:56.000 --> 00:29:01.200 unexplained anemia. Also certain systemic. This is like systemic processes and SLE 385 00:29:01.200 --> 00:29:05.500 which can also result in an effort between these are also things 386 00:29:05.500 --> 00:29:09.300 we have to consider which could be not related to diabetes as 387 00:29:09.300 --> 00:29:14.400 well. We should be for these to the nephrologists. So prevention 388 00:29:14.400 --> 00:29:19.400 and delay. Being an Enterprise as well as being. a public 389 00:29:19.400 --> 00:29:24.400 health specialist, I would focus on the prevention, how To delay 390 00:29:24.400 --> 00:29:30.000 progression of diabetic property before we start with the treatment. So 391 00:29:30.000 --> 00:29:33.900 we should achieve blood glucose level in Norman range and which can 392 00:29:33.900 --> 00:29:38.700 obviously delay the start or progressional microbial to macro when, you know, 393 00:29:38.700 --> 00:29:41.200 we don't know for we know from the DC City and the 394 00:29:41.200 --> 00:29:45.800 UK PDS trials. The lowering the BP reduces development of kidney disease. 395 00:29:45.800 --> 00:29:48.300 Like I mentioned it should be targeted. We should be 130 by 396 00:29:48.300 --> 00:29:52.400 80 early in the course of my property and 120 by 7 397 00:29:52.400 --> 00:29:56.100 less than 120% 17 in the latest stages of everything. According to 398 00:29:56.100 --> 00:30:00.200 the decision. Intensively managed group had 40%, increase in the occurrence of 399 00:30:00.200 --> 00:30:03.700 microalgae area and 50% decrease in the grounds of macro. And this 400 00:30:03.700 --> 00:30:06.500 is a landmark trial for type 1 diabetic patients, just like the 401 00:30:06.500 --> 00:30:11.000 UK PDS as a landmark rifle type 2 diabetic, patients and both 402 00:30:11.000 --> 00:30:16.100 have shown significant reduction in microvascular complications of diabetes. 403 00:30:16.100 --> 00:30:19.600 Because I mentioned the pathogenesis of the microvascular complications, have a common 404 00:30:19.600 --> 00:30:24.300 Mainstay on a common etiology and common pathophysiology. So my final thoughts 405 00:30:24.300 --> 00:30:29.300 in order to sum up, what I've mentioned in great details, throughout 406 00:30:29.300 --> 00:30:32.300 the course of the webinar, is a diving effort. That is a 407 00:30:32.300 --> 00:30:36.200 disease that develops slowly. And if treated early progression can be delayed, 408 00:30:36.200 --> 00:30:41.600 like I mentioned diabetic nephropathy is the leading cause of ESRD. Like 409 00:30:41.600 --> 00:30:46.300 I mentioned in Taekwondo diabetic, patients, their prone to develop ESRD almost 410 00:30:46.300 --> 00:30:50.900 like a mentioned 50% in the first 10 years and greater than 411 00:30:50.900 --> 00:30:56.000 75% in the 15th of diabetes. Type 412 00:30:56.000 --> 00:31:00.100 2 diabetic patients, almost 25% developed is one of the leading causes. 413 00:31:01.300 --> 00:31:04.000 There are no signs and symptoms of early disease. So, screening is 414 00:31:04.000 --> 00:31:07.800 very much important only in advance of kidney disease where there be 415 00:31:07.800 --> 00:31:11.000 some signs and symptoms of uranium, but not in the early stages 416 00:31:11.000 --> 00:31:17.400 dabbing, their properties potentially reversible with intense early treatment. Aggressive 417 00:31:17.400 --> 00:31:21.700 treatment of blood, glucose blood pressure lipids, help in prevention of renal 418 00:31:21.700 --> 00:31:27.000 function, and can improve the outcomes timely specialist Nephrology referral. Like, I 419 00:31:27.000 --> 00:31:29.800 mentioned, has an important role in mountainous. So many team approach to 420 00:31:29.800 --> 00:31:35.200 slow down dabbling. A property, not just our nephrologist internist or 421 00:31:35.200 --> 00:31:40.200 cardiologist nutritionist. These are also very much important 422 00:31:40.200 --> 00:31:45.200 laws. Even the diabetes educator have an important role in this multidisciplinary 423 00:31:45.200 --> 00:31:50.500 team approach along with the Enterprise, or the targets. So 424 00:31:50.500 --> 00:31:55.600 if you want to 12 more further into this topic, this paper 425 00:31:55.600 --> 00:32:01.700 that I published early on in 2020 where I mentioned in details 426 00:32:01.700 --> 00:32:06.100 about the diving after he is a comprehensive review for healthcare professionals, 427 00:32:06.100 --> 00:32:08.800 you can get it because it's been published in the international Journal 428 00:32:08.800 --> 00:32:13.300 of diabetes and Enterprise. And so, thank you very much. That was 429 00:32:13.300 --> 00:32:18.600 the end of my topic and I'd like to address 430 00:32:18.600 --> 00:32:23.600 Varsity for giving me this opportunity to speak on this very important 431 00:32:23.600 --> 00:32:28.500 topic today. Thank you so much. The session was very enlightening throughout 432 00:32:28.500 --> 00:32:33.100 and I'm sure we I personally also got to learn a lot 433 00:32:33.100 --> 00:32:37.000 throughout this session. I'm sure we was will also get to learn 434 00:32:37.000 --> 00:32:42.000 from these session. So we have few questions with your permission, 435 00:32:42.000 --> 00:32:47.900 shall we moved with those? Here. All right, so some 436 00:32:47.900 --> 00:32:51.400 moving on to the first question that is, what is the role 437 00:32:51.400 --> 00:32:56.600 of hypoglycemia induced oxidative stress in the development and progression 438 00:32:56.600 --> 00:33:01.800 of diabetic nephropathy? Like I mentioned, there are two main Pathways over 439 00:33:01.800 --> 00:33:05.500 here, the hemodynamic as well as metabolic factors of metabolic factors. If 440 00:33:05.500 --> 00:33:10.100 you take into consideration the advanced position and products projects or oxidation 441 00:33:10.100 --> 00:33:15.100 like reactive oxygen species. These are all these are main features 442 00:33:15.100 --> 00:33:20.200 that are involved in the pathogenesis of microvascular complications. So 443 00:33:20.200 --> 00:33:25.200 we should address these now, just looking in into the diabetes technology 444 00:33:25.200 --> 00:33:30.400 where and now these Advanced nation and products have also been implemented 445 00:33:30.400 --> 00:33:34.100 in some of the smart watches now and Samsung has come out 446 00:33:34.100 --> 00:33:39.100 with the New watch Ultra, which has 447 00:33:39.100 --> 00:33:43.700 features which can monitor these Advanced relationship and products. So it's very 448 00:33:43.700 --> 00:33:48.800 important. These reactive, oxygen species. Are one question and not just for 449 00:33:48.800 --> 00:33:53.900 development or directly but also in European the same Pathways involved 450 00:33:53.900 --> 00:33:58.300 those orbital as well as the polio Pathways the same password in 451 00:33:58.300 --> 00:34:03.500 the original. When we look into the common mechanisms for all microvascular 452 00:34:03.500 --> 00:34:08.500 complications. it's a very lightly said some moving on to 453 00:34:08.500 --> 00:34:13.600 the next question that is how does a glycemic variability impact renal 454 00:34:13.600 --> 00:34:17.900 outcomes in diabetic patients and what are few strategies that can be 455 00:34:17.900 --> 00:34:23.700 employed to minimize the fluctuations, according to you Now 456 00:34:23.700 --> 00:34:27.600 how do we measure? What glucose is very much important for us 457 00:34:27.600 --> 00:34:32.400 previously? We used to use smbg as we want to see and 458 00:34:32.400 --> 00:34:37.100 blood glucose level. We used to monitor fasting levels and after breakfast 459 00:34:37.100 --> 00:34:41.100 or after dinner, But now, we have to go into the future. 460 00:34:41.100 --> 00:34:46.800 And with the onset of CGM and time 461 00:34:46.800 --> 00:34:50.300 and range, we should also control of them because these blood glucose 462 00:34:50.300 --> 00:34:54.800 variations, we cannot measure with SV. Once a day, it has limitations, 463 00:34:54.800 --> 00:34:58.000 but the time and range is very much important for us. And 464 00:34:58.000 --> 00:35:01.300 so we should address first the time in range. It should be 465 00:35:01.300 --> 00:35:06.800 within some range, get good, clinical 466 00:35:06.800 --> 00:35:12.600 outcomes of diabetes very important for us to Reduce our 467 00:35:12.600 --> 00:35:15.700 blood sugar early in the course of the disease but type 1 468 00:35:15.700 --> 00:35:18.500 diabetic patients. Of course, insulin is the only treatment that is available 469 00:35:18.500 --> 00:35:22.600 for type 2 diabetic patients. There are many treatment options available and 470 00:35:22.600 --> 00:35:27.700 like I mentioned the Ada AAC or all have recommended that we 471 00:35:27.700 --> 00:35:32.400 should start sdl Inhibitors when there's a there's a clinical evidence of 472 00:35:32.400 --> 00:35:37.500 either artistic cardiovascular disease, or labeling, 473 00:35:37.500 --> 00:35:41.500 a property or Advanced kidney disease. Because here we can see that 474 00:35:41.500 --> 00:35:46.800 these drugs can reduce The progression of diving 475 00:35:46.800 --> 00:35:49.900 effort, everything also like a mentioned. Blood pressure control is very much 476 00:35:49.900 --> 00:35:55.100 important for us as in America's as well as minor chord with 477 00:35:55.100 --> 00:35:58.900 subtracting is also is a new drug that has been developed. These 478 00:35:58.900 --> 00:36:02.800 are all so very much important for us. So if you want 479 00:36:02.800 --> 00:36:06.500 to slow down the progression of diving effort button. So early on, 480 00:36:06.500 --> 00:36:09.400 if you can control the blood sugar, like we've seen with the 481 00:36:09.400 --> 00:36:14.100 UK pdst, studies entirely patients. We've seen this with the DC City 482 00:36:14.100 --> 00:36:18.300 and the electrons in the type 1 diabetic, patients, almost 40 to 483 00:36:18.300 --> 00:36:23.200 50% reduction in my career, if we can reduce the blood glucose 484 00:36:23.200 --> 00:36:25.900 control early in the course of the disease, as well as ACE 485 00:36:25.900 --> 00:36:31.000 inhibitors, we should start early if there's presence of microbial is 486 00:36:31.000 --> 00:36:36.200 the if there is irrespective of blood blood pressure, If 487 00:36:36.200 --> 00:36:39.800 there is microbial with diabetes, you should start a centimeters because we 488 00:36:39.800 --> 00:36:43.200 have seen from the trials, various trials, that almost 40 to 50% 489 00:36:43.200 --> 00:36:49.100 microorganisms by just a centimeter arbs what we should monitor. 490 00:36:49.100 --> 00:36:52.800 Like, I mentioned the potassium levels as well as we should monitor, 491 00:36:52.800 --> 00:36:57.800 the creatinine levels because it's bound to cause Aki. So those not 492 00:36:57.800 --> 00:37:01.200 all, not in all cases, but it does and we should monitor 493 00:37:01.200 --> 00:37:06.300 it. Periodically, All right. Some moving on 494 00:37:06.300 --> 00:37:09.700 to the next question. I think this will be the last question 495 00:37:09.700 --> 00:37:15.000 for today's session. That is how does hypertension interact with diabetes to 496 00:37:15.000 --> 00:37:19.800 accelerate renal impairment and what are the best practices for managing blood 497 00:37:19.800 --> 00:37:24.800 pressure, blood pressure and basically this sort of patients, It's 498 00:37:24.800 --> 00:37:30.300 a very interesting question. We should. It's like the question of interlinked. 499 00:37:30.300 --> 00:37:34.400 Did the egg come before the chicken or the chicken came before 500 00:37:34.400 --> 00:37:38.800 the day? Yeah, what does does hypertension cause diabetes or does diabetes 501 00:37:38.800 --> 00:37:44.000 cause hypertension? Like I mentioned the diabetic nephropathy due to hypertension is 502 00:37:44.000 --> 00:37:49.100 a secondary cause of hypertension. Secondary causes of hypertension is more involve 503 00:37:49.100 --> 00:37:53.200 over here, as well as even essential hypertension can also cause Nefertiti 504 00:37:53.200 --> 00:37:58.500 in these patients. So it's a very interesting question and obviously hypertension 505 00:37:58.500 --> 00:38:01.600 as well as blood glucose comes from. These are the main factors 506 00:38:01.600 --> 00:38:06.700 that are involved in the development of driving efforts of mention other 507 00:38:06.700 --> 00:38:11.000 risk factors, like genetic factors we associate Asians, I don't know is 508 00:38:11.000 --> 00:38:13.900 because of our diet, or is it because of a lifestyle we 509 00:38:13.900 --> 00:38:16.800 are more prone to develop diabetes as well as we are more 510 00:38:16.800 --> 00:38:21.600 prone to developing their property. Smoking in our is more predominant in 511 00:38:21.600 --> 00:38:26.700 our population rather than the Western population. Or population is also 512 00:38:26.700 --> 00:38:29.700 higher than the Western population, so that we have to take into 513 00:38:29.700 --> 00:38:34.700 consideration, our genetic history of taking the conservation. Um so these 514 00:38:34.700 --> 00:38:37.800 are some factors that we have to look into and dwell into 515 00:38:37.800 --> 00:38:43.700 hypertension and not glucose. These are two different different 516 00:38:43.700 --> 00:38:48.200 Pathways that can result in their property hypertension affects one system and 517 00:38:48.200 --> 00:38:52.500 diabetes affects another system. Like I mentioned when I mentioned the pathophysiology 518 00:38:52.500 --> 00:38:57.300 there's a globular basement membrane thinking thickening there's a messenger cell configuration 519 00:38:57.300 --> 00:39:02.300 which results in advanced glamorous sclerosis as well as. Finally 520 00:39:02.300 --> 00:39:07.400 they have the two Berlin's industrial proliferation which regards in two 521 00:39:07.400 --> 00:39:10.900 ways in the social damage and finally damage to the track kidney. 522 00:39:10.900 --> 00:39:15.000 So this is a complex process which takes years to develop, it 523 00:39:15.000 --> 00:39:19.600 doesn't have develop abruptly. If a, we have to look into the 524 00:39:19.600 --> 00:39:24.100 other costs, like I mentioned before that, there's other causes which could 525 00:39:24.100 --> 00:39:28.900 refer to the nephrologists, but yes, blood pressure control. Blood glucose control 526 00:39:28.900 --> 00:39:33.700 is very much. Its most important option for us, for reducing the 527 00:39:33.700 --> 00:39:38.500 risk of kidney disease progression. I hope I answered the question. Like 528 00:39:38.500 --> 00:39:42.000 I mentioned this, a very difficult question to answer because these are 529 00:39:42.000 --> 00:39:46.600 two different Pathways involved and which comes before the other, we cannot 530 00:39:46.600 --> 00:39:52.200 see. Absolutely so. But very rightly mentioned and thank you with 531 00:39:52.200 --> 00:39:54.600 this. I would like to thank you so much for taking out 532 00:39:54.600 --> 00:39:59.000 time from your busy schedule and doing this session for us. Like 533 00:39:59.000 --> 00:40:02.400 I mentioned our viewers will get to learn and get to extract. 534 00:40:02.400 --> 00:40:05.900 A lot of information out from this session. We are really looking 535 00:40:05.900 --> 00:40:09.100 forward. To have you again on our platform really soon with such 536 00:40:09.100 --> 00:40:12.200 amazing topic and I hope you had a great time here with 537 00:40:12.200 --> 00:40:15.100 us. Thank you very much for watching this problem and thank you 538 00:40:15.100 --> 00:40:20.400 for giving me this opportunity to talk about The 539 00:40:20.400 --> 00:40:21.200 topic today. Thank you.