Change Strategy for Diabetic Nephropathy

Change Strategy for Diabetic Nephropathy Diabetic Nephropathy is a progressive kidney infection caused by injury to the blood vessels in the kidneys due to high blood sugar levels, it is associated with diabetes, and it can lead to endstage renal disease (ESRD) if not managed appropriately. DN is a major risk factor for developing infections in diabetic patients due to immunological dysfunction, high glucose levels, and complications with circulation (Forst et al., 2022). The data below are from a hospital setting for a patient who has not responded to medications and care.

Clinical Outcome

Patient’s status.

1st Visit.

153/90 11.0

Current 143/88 8.3

4-6 4 – 5.6 Absent

HDL cholesterol (mg/dl) LDL cholesterol (mg/dl) Triglycerides (mg/dl) Glomerular Filtration Rate (mL/min/1.73 m2.)

Serum Creatinine (mg/dl) Serum Albumin (g/dl) Body Mass Index (kg/m^2) Medications

30 90 152 127

7.5 6.0 Present (Traces) 28 80 150 120

0.74 – 1.35 3.4 – 5.4 18.5 – 24.9 A complete response to medication.

Dietary Habits Physical Activity

Poor Sedentary lifestyle

1.01 4.4 26.3 ACE Inhibitors Insulin Diuretics Statins Improved Adjusting

Smoking

Not smoking

Not smoking

Blood Pressure (mmHg) Random blood sugar (mmol/L) Fasting blood sugar (mmol/L) 9.2 Hemoglobin A1C (%) 4.2 Urine Protein Present (+++)

0.80 4.5 26.4 No medication.

Desired outcomes 120/80 Less than 7.9

35- 65 Lower than 100 Less than 150 90-120

Healthy Regular exercise routine Should not smoke

Table 1: Showing male adult patients on acute care clinical outcomes for one month (February 2023).

Note: The table has not provided information about the specific doses or frequency of the medications prescribed, the duration of the treatment plan, any potential side effects, or any other lifestyle changes recommended, such as reducing alcohol intake or managing stress.

Additionally, the table does not provide information about any other comorbidities or health conditions that may impact the management of diabetic Nephropathy.

The goal of this change strategy The goal is to improve the patient's overall health status by achieving desirable clinical outcomes: Manage glycemic control Control blood pressure Manage cholesterol levels Improve the patient's diet and physical activity levels.

The proposed change strategies below will improve quality by addressing the patient's health issues and overall health status, resulting in reduced hospitalizations, fewer complications, and improved patient satisfaction. The strategies will also promote safety by reducing the risk of adverse events associated with poorly managed chronic conditions.

Proposed Change.

The following proposed strategies are cost-effective for they involve the substation of a drug, monitoring adherence to a continuation of a drug/diet, or just physical exercise. The change strategies will also result in additional workload and time commitments for the care team.

Furthermore, the team may need to adjust their workflow and communication processes to ensure efficient and effective collaboration.

1. Medication Management.

Traditionally, controlling blood sugar and blood pressure has been the most important part of preventing and treating diabetic kidney disease. ACE inhibitors are the best drugs for treating high blood pressure. However, suppose a patient does not respond to them. Combining an ACE inhibitor and a dihydropyridine calcium channel blocker is better because it protects against cardiovascular events than combining the same ACE inhibitor and a thiazide diuretic (Forst et al., 2022). Combining an ACE inhibitor (or ARB) with a thiazide diuretic is also a good idea, especially for people with conditions that can be helped by a thiazide diuretic (edema, osteoporosis, calcium nephrolithiasis with hypercalciuria). Combination therapy lowers blood pressure more than a single treatment and makes it more likely that the blood pressure goal will be reached in a reasonable amount of time (Forst et al., 2022). The goal of blood pressure may also be reached with lower doses of each drug when two are used; this lowers the risk of side effects caused by the doses. ACE inhibitors will also help control the amount of protein in the urine. So, our new plan is to combine ACE inhibitors and dihydropyridine calcium channels into a single pill.

The patient has not responded well to insulin therapy and needs more medicine to lower their blood sugar. Sharaf El Din et al. (2017) confirmed in their article that Insulin could be used with other drugs because it works independently. Canagliflozin is more effective than glimepiride at controlling blood sugar levels because eGFR goes down less in people taking canagliflozin than in people taking glimepiride, even though HbA1c goes down the same amount. Canagliflozin

was also found to have renoprotective effects that were separate from its effect on blood sugar. It also lowered body weight and blood pressure in T2DM patients with stage 3a and stage 3b CKD (Sharaf El Din et al., 2017). We would change how we stabilize blood sugar by giving canagliflozin and insulin therapy.

Intensively lowering lipids is an important part of managing diabetes since diabetes is thought to be the same as coronary heart disease. Table 1 shows that the statins the patient has been taking to lower his lipids level have not worked properly. Even though high doses of statins have been linked to better results in lowering lipids, increasing the dose of statins is sometimes a good idea or even safe. Statins may cause side effects like myopathy and a higher risk of Type 2 diabetes (de Bhails et al., 2021). Based on what we have learned, our new plan for lowering lipid levels is not to increase the statin dose but to give a combination of statin and fibrate therapy. The combination changes the lipid profile of T2DM in a good way.

Treatment with vitamin D receptor agonists (paricalcitol 2 g per day) has been shown to reduce the amount of albumin in the urine by a large amount (de Bhails et al., 2021). So, it will be one of the ways we change our plan to lower the albumin in the urine.

The glomerular filtration rate of the patient can be improved with bardoxolone methyl. Clinical trials (de Bhails et al., 2021) have shown that it is good for people with type 2 diabetes and chronic kidney disease (CKD). Since the GFR of the patient is still high, the new plan will also include bardoxolone.

2. Dietary Management: The data collected (Table 1) does not show if the patient has been told to cut back on salt. Both de Bhails et al. (2021) and Sharaf El Din et al. (2017) recommends limiting salt intake to less than 100 mmol (5–6 g) per day, as this can significantly lower blood pressure and urinary albumin excretion. Getting less salt in the diet goes hand in hand with getting more potassium, which also helps lower blood pressure and keep the kidneys working well. High potassium makes people lose more sodium through their urine. Potassium also makes blood vessel walls less tight, which helps to lower blood pressure even more (Varghese, R. T. et al. 2021); this can be done if the nurse, doctor, and dietitian work together to change the strategy.

Protein restriction should also be suggested. The best protein for the patient to eat daily is 0.8 g/kg (Varghese, R. T. et al. 2021). Forst et al. (2022) and Sharaf El Din et al. (2017) found that switching to a mostly vegetarian diet helped lower the amount of albumin in the urine. Based on the above results, the dietitian and caretaker will also tell the patient to cut back on protein and switch to a vegetable-based diet.

Another change in how the patient's diet is managed is that they will be given foods that are high in vitamin D. Vitamin D makes the body more sensitive to Insulin, which lowers the risk of insulin resistance, which is often a sign that a person will develop type 2 diabetes (Forst et al., 2022).

Another way to help lower blood sugar levels would be to tell the patient to follow a lowcarbohydrate diet. Carbohydrates raise blood sugar levels more than other foods, so the body has

to make more Insulin to break them down. Fewer carbs can help stabilize blood sugar (Forst et al., 2022).

3. Physical Activity: Getting the patient into a regular exercise routine will make him or her more active. The patient will be told to do regular physical activity for at least 30 minutes daily, five days a week, such as brisk walking, jogging, or cycling; this will help improve their blood sugar, blood pressure, glomerular filtration rate, and body mass index (Forst et al., 2022).

4.

Patient Education

The care team will use "teach-back" methods to ensure patients understand what they are told.

The patient will learn about their condition and why taking their medicine as prescribed is important, living a healthy life, and going to regular follow-up appointments. The patient's caretaker will also be told about the changes and how important each is to the patient's recovery and to keep them from getting other infections.

Inter-professional Considerations A pharmacist, nurse, caregiver, and doctor will work together on the medication management plan to ensure that the right medicines are prescribed and that the patient knows how to take them correctly. Lab techs will also come in later to test how the patient responds to treatment and follow-ups.

The nurse, doctor, and registered dietitian will work together as part of the dietary management plan to give nutritional advice and make a personalized meal plan that fits the patient's culture and food preferences.

Communication and Carrying Out The strategies for change will be explained to the patient and their family clearly and directly to make sure they understand and get involved. The care team will use a patient-centered approach to ensure the patient's preferences and needs are met and include the patient in the decisionmaking process.

REFERENCES. Sharaf El Din, U. A., Mansour Salem, M., & Abdulazim, D. O. (2017). Recent advances in the management of diabetic Nephropathy. Journal of Clinical & Experimental Nephrology, 02(02). https://doi.org/10.21767/2472-5056.100035

Varghese, R. T., Jialal, I., & Doerr, C. (2021). Diabetic Nephropathy (nursing). In StatPearls [Internet]. StatPearls Publishing.

Forst, T., Mathieu, C., Giorgino, F., Wheeler, D. C., Papanas, N., Schmieder, R. E., Halabi, A., Schnell, O., Streckbein, M., & Tuttle, K. R. (2022, October 10). New strategies to improve clinical outcomes for diabetic kidney disease - BMC medicine. BioMed Central. Retrieved March 15, 2023, from https://doi.org/10.1186/s12916-022-02539-2 de Bhailís, Á. M., Azmi, S., & Kalra, P. A. (2021). Diabetic kidney disease: Update on clinical management and non-glycaemic effects of newer medications for type 2 diabetes. Therapeutic Advances in Endocrinology and Metabolism, 12, 204201882110206. https://doi.org/10.1177/20420188211020664