Renal Vascular Resistanceand Diabetes
Vijaya Juturu, Ph.D., F.A.C.N.

©2010 Wolf Rinke Associates, Inc. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, without the prior written permission of the Publisher.

CUSTOMER COMMENTS

Deirdre Nickels: "Very good information that I can apply to my career objectives to better serve my patients."

OVERVIEW AND INTRODUCTION

Welcome to Renal Vascular Resistance and Diabetes, a self-directed, accredited learning program. Diabetic nephropathy is a common microvascular complication in diabetic patients and may lead to chronic renal failure. Alterations in vascular compartments of the kidneys may lead to changes in renal vascular resistance.
The excretory and regulatory processes depend on the blood supply to the kidney. It receives the highest blood flow per gram of organ weight in the body at 1 liter/min. As blood flows through these vascular organs, its composition is appropriately altered according to homeostatic requirements. Renal fraction is the fraction of the total cardiac output that flows through the kidneys. Blood flow to the kidneys will be dependent on a number of important systemic factors.
This self-directed, accredited learning program will provide you with detailed information that will enable you to understand and apply concepts associated with renal vascular resistance and diabetes including:

This learning program is designed to help you earn 16 continuing professional education units (CPEUs). It is a category 2 Continuing Professional Education (CPE) program, meaning that the reader has general knowledge of the literature and professional practice within the area covered. The focus of the program is to enhance knowledge and application.
To get the most out of this program, it is suggested that you follow these four steps:
Step 1: Read the material presented in each of the chapters.
Step 2: When you come to an example, stop for a moment and work out the answers using pen and paper.
Step 3: Assess what you have learned by completing the self-assessment instrument contained at the end of the learning program.
Step 4: Compare your answers to the answer key contained at the end of the learning program. If you score at least 80% correct, you have completed this program and are ready to transfer your answers to the CONTINUING PROFESSIONAL EDUCATION REPORTING FORM. If you scored less than 80% correct, re-read the learning program until you score at least 80% correct.
After you have successfully completed the program, complete the CPE CONTINUING PROFESSIONAL EDUCATION REPORTING FORM and
Mail to: Wolf Rinke Associates, Inc., P.O. Box 350, Clarksville, MD 21029,
Or Fax to: (410) 531-9282,
Or submit On-line at www.easyCPEcredits.com.
Once they receive your successfully completed CONTINUING PROFESSIONAL EDUCATION REPORTING FORM they will send you a certificate of completion.
Happy Learning!
Vijaya Juturu., Ph.D., F.A.C.N.

GOAL AND EDUCATIONAL OBJECTIVES
Goal
To provide you with practical information that will enable you to understand and apply the concepts concerning renal hemodynamics, structural alterations of kidneys and renal vascular resistance in diabetes.

Educational Objectives
Upon completion of this accredited, self-directed learning program you should be able to:

TABLE OF CONTENTS

Chapter I: Diabetes Mellitus 1
Types of Diabetes Mellitus 1
Type 1 Diabetes Mellitus (T1DM) 1
Type 2 Diabetes Mellitus 3
Gestational Diabetes Mellitus 4
Other Specific Types of Diabetes: Genetic Defects of Beta Cell Function
(MODY and Others) 5
Complications of Diabetes 6
Diabetic Retinopathy 6
Diabetic Nephropathy 7
Diabetic Neuropathy 7
Diabetic Amyotrophy 7
Diabetic Ketoacidosis 8
Gastroparesis 8
Alzheimer's Disease 8
Diabetic Coma 9
Sexual and Urological Problems 9
Skin Problems 10
Bone Health 10
Pathophysiology of Type 1 Diabetes Mellitus (T1DM) 10
Pathophysiology of Type 2 Diabetes Mellitus (T2DM) 11
Diagnosis of Diabetes 12
Fasting Plasma Glucose (FPG) Test 12
Oral Glucose Tolerance Test (OGTT) 13
Random Plasma Glucose Test 13
Prevention and Treatment 13
Estimated Average Glucose (eAG) 17

Chapter II: Kidneys: Structure and Physiology 19
Structure 19
Nephron 20
Physiology 22
Oxygen Consumption in the Kidneys 22
Glomerular Filtration Rate (GFR) 22
Renal Blood Flow 23
Renal Vascular Pressure Gradients 23
Autoregulation 23
Autoregulation of GFR via afferent and efferent arterioles 23

Chapter III: Hemodynamics and Renal Hemodynamics 27
Hemodynamics 27
Renal Hemodynamics 28
Factors Associated with Changes in Renal Hemodynamics 29
Diabetes 29
Calcium and Potassium Channels 29
Tubuloglomerular Feedback 30
Myogenic Response 30
Atrial Natriuretic Peptide 30
Renin-Angiotensin System 31
Obesity 32
Hypertension 32
Cardiovascular Disease 33

Chapter IV: Glomerular Hemodynamics and Structural Alterations 37
Glomerulosclerosis 39
Glomerular Hemodynamics in Obesity 39
Glomerular Hemodynamics in Insulin Resistance and Hypertension 40

Chapter V: Renal Resistance Index 43
RI and Diabetes 44

Chapter VI: Hyperfiltration and Diabetic Nephropathy 49
Renal Hemodynamic Changes in T1DM 49
Effects of Strict Metabolic Control on Glomerular Hemodynamics in Diabetes Mellitus 50
Glomerular Hemodynamic Alterations in Diabetic Nephropathy 51
Structural Changes 51
Kidney Size 51
Natural Course and Stages of Diabetic Nephropathy 52

Chapter VII: Determinants of Renal Vascular Resistance 59
Neurogenic/Adrenergic Control 59
Sympathetic Control of Renal Hemodynamics 59
Adrenoceptors 59
Pulse Pressure and Mean Arterial Pressure 60
Intrinsic Factors 60
Autoregulation 60
Renin-angiotensin 60
Eicosanoids 60
Kinin-Kallikrein 61
Extrinsic Factors 61
Sympathetic nervous system 61
Angiotensin II 62

Chapter VIII: Conditions Associated With Renal Vascular Resistance 65
Kidney Obstruction 65
Acute Tubular Necrosis 65
Acute Transplant Rejection 65
Renal Artery Stenosis (RAS) 66
Chapter IX: Screening for Kidney Disease 69
Renal Assessments 69
Glomerular Filtration Rate (GFR) 69
The Concept of Clearance 70
Blood Urea 72
Blood Urea Nitrogen 72
Serum Creatinine 72
Serum and Urine Osmolality 73
Urinary Urea Nitrogen 73
Uric Acid 74
Diabetes Assessments 74
Plasma Glucose 74
Plasma Glycosylated Hemoglobin (HbA1c) 75
c-Peptide 76
Enzyme Tests 76
Urine Tests 76
Glucose Test 76
Ketone Test 77
Microalbuminuria Test 77
Creatinine Test 77
White Blood Cell (leukocyte) Test 77
Nitrite Test 77
Urine Specific Gravity Test 77
Urine pH Test 77
Other Tests 78
Hyperinsulinemic-euglycemic Clamp 78
Fluorescein Angiography (Test for Diabetic Retinopathy) 78
Diabetic Nephropathy - Kidney Biopsy 78
Ultrasound 79
Coronary Heart Disease Assessments 79
Echocardiography 79
Carotid Ultrasound Imaging 79
Dobutamine Stress Echocardiography 79
Exercise ECG Stress Testing 80
Exercise Stress Echocardiography 80
Dyslipidemia 80
Hypertension Assessments 81
Ambulatory Blood Pressure Monitoring 81
Endothelial Functions 82
Peripheral Arterial Tonometry (PAT) 82
Brachial Artery Ultrasound Imaging 82
Obesity Assessments 83
Body fat distribution 83

Chapter X: Management of Renal Vascular Resistance in Diabetes 87
Glycemic control 87
Periodic Evaluations 88
Medical History 88
Physical Examination 88
Glucose Monitoring 89
Monitoring for Diabetic Complications 90
Patient Education 91
Medical Record Documentation 91
Cholesterol Monitoring 92
Cholesterol Goals for Patients with Diabetes 92
Body Weight Monitoring and Weight Management Goals 93
Blood Pressure Monitoring 93

Chapter XI: Evidence-Based Guidelines and Quality Health Care 97
Evidence-Based Guidelines 97
Quality Health Care 98
Management of CKD 99

Conclusions 103
References 105
Resources 113
List of Abbreviations 115
Glossary 121
Self-Assessment Questions 143
Answer Key 161
Explanation of Answers 163
About the Author 171
About Wolf Rinke Associates, Inc. 172

ABOUT THE AUTHOR

Dr. Juturu has a doctoral degree in Clinical Nutrition (Cardiovascular Nutrition) from S.V. University in India (1996) and completed her Post Doctoral Research in Cardiovascular Nutrition at Penn State University (1997-2000). Dr. Juturu is working as a consultant for research and development to consumer research companies and adjunct faculty. She is an expert panel member of European Food Safety Authory (EFSA). She worked as Senior Scientist and then as Director of Scientific Affairs at Nutrition 21, Inc. in Purchase, NY, from 2001 to August 2008.
Dr. Juturu is the recipient of the Dr. Tinsley R. Harrison Award in 2008 from The Society of Clinical Investigation (SSCI) and the American Journal of Medical Sciences; Dr. Mark Bieber, Distinguished Industry Scientist Award in 2008 from the American College of Nutrition, the Young Scientist Award given by the Indian Society of Atherosclerosis Research in 1995, and the Indian Medical Scientist Award in Nutritional Sciences, given by the Indian Council of Medical Research in 1997. She received the Diabetes Education Stipend Award in 2005 and the Diabetes Care Education and Professional Excellence Award in 2007 from the Nutrition in Complementary Care Dietetic Practice Groups of the American Dietetic Association (ADA).
Dr. Juturu is the author of several publications including book chapters, patents and submissions of qualified health claims. She is an invited author, invited speaker, reviewer, council/committee member and editorial board member for several reputed journals. She was nominated as Research and Development Chair for the Medical Nutrition Practice Group of ADA, nominated to HOD/PID research and development, and is working as an Evidence Analysis Library analyst/committee member for ADA, and is involved in a women's working group committee of the American Diabetes Association.
Dr. Juturu is a member of numerous professional organizations including the American Diabetes Association, American Heart Association, American Society for Nutritional Sciences, American College of Nutrition, and the American Oil Chemists Society. She is a consultant of the United Soybean Board, Natural Standard of Integrative Medicine, Cochrane Research Group and a Fellow of the American College of Nutrition (F.A.C.N.). Dr. Juturu resides in New York with her husband and daughter.