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

©2012 Wolf Rinke Associates. 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.

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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, which receives the highest blood flow per gram of organ weight in the body at 1 liter/min. As blood flows through this vascular organ, 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 level 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.
To receive your well deserved 16 CPEUs you must complete the CPE REPORTING FORM and
Submit it on-line at www.easyCPEcredits.com,
Or fax to: (410) 531-9282,
Or mail to: Wolf Rinke Associates, 721 Valley Forge Road #486, Valley Forge, PA 19481.
Upon receipt of your CPE Reporting Form, we will email you a Certificate of Completion within 3-5 days.
When you submit your CPE Reporting Form to us via www.easyCPEcredits.com, fax, or mail be sure to write your correct email address in the space provided on the CPE Reporting Form. If writing by hand, be sure to print your email address clearly.

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 the 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 7
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
Depression 12
Pathophysiology of Type 1 Diabetes Mellitus (T1DM) 13
Pathophysiology of Type 2 Diabetes Mellitus (T2DM) 14
Diagnosis of Diabetes 15
Fasting Plasma Glucose (FPG) Test 15
Oral Glucose Tolerance Test (OGTT) 16
Random Plasma Glucose Test 16
Prevention and Treatment 16
Estimated Average Glucose (eAG) 20

Chapter II: Kidneys: Structure and Physiology 22
Structure 22
Nephron 23
Dialysis and Transplantation 25
Hemodialysis 26
Continuous Ambulatory Peritoneal Dialysis (CAPD) 26
Physiology 28
Oxygen Consumption in the Kidneys 29
Glomerular Filtration Rate (GFR) 29
Renal Blood Flow 30
Renal Vascular Pressure Gradients 30
Autoregulation 30
Autoregulation of GFR via Afferent and Efferent Arterioles 30
Case Study 31
Commentary 32

Chapter III: Hemodynamics and Renal Hemodynamics 33
Hemodynamics 33
Renal Hemodynamics 34
Renal Hemodynamic Changes in Diabetes 35
Factors Associated with Changes in Renal Hemodynamics 35
Diabetes 35
Calcium and Potassium Channels 36
Tubuloglomerular Feedback 36
Myogenic Response 36
Atrial Natriuretic Peptide 37
Renin-Angiotensin System 37
Obesity 38
Hypertension 39
Cardiovascular Disease 39
Case Study 40
Commentary 42

Chapter IV: Glomerular Hemodynamics and Structural Alterations 43
Glomerulosclerosis 45
Glomerular Hemodynamics in Obesity 46
Glomerular Hemodynamics in Insulin Resistance and Hypertension 46
Case Study 47
Commentary 48

Chapter V: Renal Resistance Index 49
Doppler Sonographic Assessment of Renal Resistance Index (RRI) 50
RI and Diabetes 50
Case Study 52
Commentary 53

Chapter VI: Hyperfiltration and Diabetic Nephropathy 54
Renal Hemodynamic Changes in T1DM 54
Effects of Strict Metabolic Control on Glomerular Hemodynamics in Diabetes Mellitus 55
Glomerular Hemodynamic Alterations in Diabetic Nephropathy 56
Structural Changes 56
Kidney Size 56
Natural Course and Stages of Diabetic Nephropathy 57
Biomarkers of Glomerular Injury in Diabetic Nephropathy 62
Case Study 62
Commentary 63

Chapter VII: Determinants of Renal Vascular Resistance 64
Neurogenic/Adrenergic Control 64
Sympathetic Control of Renal Hemodynamics 64
Adrenoceptors 64
Pulse Pressure and Mean Arterial Pressure 64
Intrinsic Factors 65
Autoregulation 65
Renin-Angiotensin 65
Eicosanoids 65
Kinin-Kallikrein 66
Extrinsic Factors 66
Sympathetic Nervous System 66
Angiotensin II 67
Case Study 68
Commentary 68

Chapter VIII: Conditions Associated With Renal Vascular Resistance 69
Kidney Obstruction 69
Acute Tubular Necrosis 69
Acute Transplant Rejection 69
Renal Artery Stenosis (RAS) 70
Functional Tests Used For the Diagnosis of Renal Artery Stenosis 70
Case Study 71
Commentary 72

Chapter IX: Screening for Kidney Disease 73
Renal Assessments 73
Glomerular Filtration Rate (GFR) 73
The Concept of Clearance 74
Calculation of Creatinine Clearance 75
Blood Urea 75
Blood Urea Nitrogen 76
Serum Creatinine 76
Serum and Urine Osmolality 76
Urinary Urea Nitrogen 77
Uric Acid 77
Diabetes Assessments 77
Plasma Glucose 78
Plasma Glycosylated Hemoglobin (HbA1c) 78
c-Peptide 80
Enzyme Tests 80
Urine Tests 80
Glucose Test 81
Ketone Test 81
Microalbuminuria Test 81
Creatinine Test 81
White Blood Cell (leukocyte) Test 81
Nitrite Test 81
Urine Specific Gravity Test 82
Urine pH Test 82
Other Tests 82
Hyperinsulinemic-Euglycemic Clamp 82
Fluorescein Angiography (Test for Diabetic Retinopathy) 82
Diabetic Nephropathy - Kidney Biopsy 82
Ultrasound 83
Coronary Heart Disease Assessments 83
Echocardiography 83
Carotid Ultrasound Imaging 83
Dobutamine Stress Echocardiography 83
Exercise ECG Stress Testing 83
Exercise Stress Echocardiography 84
Dyslipidemia 84
Hypertension Assessments 84
Ambulatory Blood Pressure Monitoring 85
Endothelial Functions 85
Peripheral Arterial Tonometry (PAT) 85
Brachial Artery Ultrasound Imaging 86
Obesity Assessments 86
Body Fat Distribution 87
Case Study 87
Commentary 88

Chapter X: Management of Renal Vascular Resistance in Diabetes 89
Glycemic Control 89
Periodic Evaluations 90
Medical History 90
Physical Examination 91
Glucose Monitoring 91
Monitoring for Diabetic Complications 92
Patient Education 93
Medical Record Documentation 93
Cholesterol Monitoring 94
Cholesterol Goals for Patients with Diabetes 94
Body Weight Monitoring and Weight Management Goals 95
Blood Pressure Monitoring 95
Case Study 95
Commentary 96
Case Study 97
Commentary 97

Chapter XI: Evidence-Based Guidelines and Quality Health Care 98
Evidence-Based Guidelines 98
Quality Health Care 99
Management of CKD 100

Conclusions 104
References 105
Resources 111
List of Abbreviations 113
Glossary 117
Self-Assessment Questions 131
Answer Key 149
Explanation of Answers 150
About the Author 157
About Wolf Rinke Associates, Inc. 158

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.