Introduction

• Dr. Anil Prasad Bhatt is a renowned expert in managing kidney diseases, with a special focus on diabetic patients.
• His approach to preventing chronic kidney disease (CKD) and delaying or stopping dialysis emphasizes:
  • Early intervention.
  • Personalized care.
  • A combination of medical, lifestyle, and innovative strategies.
• This article explores his unique treatment strategies, grounded in his expertise and nephrology principles.

Preventing CKD in Diabetic Patients

Overview of Diabetic Kidney Disease (DKD)

• DKD is a progressive condition caused by hyperglycemia-induced damage to kidney glomeruli.
• Leads to proteinuria, declining glomerular filtration rate (eGFR), and potential kidney failure if unchecked.

Dr. Bhatt’s Preventive Strategies

• Rooted in early interception with a tailored, evidence-based approach.
• Integrates cutting-edge therapies, rigorous monitoring, and patient empowerment.

Advanced Glycemic Management

• Precision Targets:
  • Customizes HbA1c goals (e.g., 6.5–7.5%) based on age, comorbidities, and hypoglycemia risk.
  • Aims for 6.5% in younger patients to minimize glomerular hyperfiltration.
  • Targets 7–8% in older patients with cardiovascular issues to avoid hypoglycemic stress.
• Technology Integration:
  • Recommends continuous glucose monitoring (CGM) systems for real-time data.
  • Helps avoid glucose spikes that damage kidney vasculature, especially in type 2 diabetes.
• Insulin Sensitizers and Kidney Protection:
  • Uses metformin (where eGFR permits) and insulin sensitizers like Lipaglyn (Saroglitazar) and IMEG-CKD (Imeglyn Hydrochloride).
  • Lipaglyn, a dual PPAR α/γ agonist, reduces triglycerides, improves insulin sensitivity, and lowers blood glucose in diabetic dyslipidemia.
  • IMEG-CKD enhances insulin secretion and sensitivity, reducing peripheral insulin resistance in type 2 diabetes.
  • Incorporates SGLT2 inhibitors like Forxiga early to reduce glucose reabsorption, lower intraglomerular pressure, and decrease albuminuria by 30–40% (EMPA-REG OUTCOME trial).

Aggressive Blood Pressure and Proteinuria Control

• RAS Inhibition as Cornerstone:
  • Employs ACE inhibitors or ARBs (e.g., Covance or losartan) to target hypertension and intrarenal hemodynamics.
  • Reduces efferent arteriolar resistance and glomerular pressure.
  • Titrates doses to achieve 30–50% proteinuria reduction while monitoring hyperkalemia and eGFR.
• Dual Blockade Consideration:
  • Explores dual RAS blockade (ACEi + ARB) or combines with mineralocorticoid receptor antagonists (e.g., Kerendia, shown in FIDELIO-DKD to slow CKD progression).
  • Highly individualized, balancing benefits against hyperkalemia risks.
• Blood Pressure Nuance:
  • Targets <130/80 mmHg, or <125/75 mmHg in heavy proteinuria cases (KDIGO guidelines).
  • Monitors to avoid hypotension, especially in elderly patients with autonomic neuropathy.

Emerging Pharmacotherapies

• SGLT2 Inhibitors:
  • Drugs like canagliflozin and Forxiga reduce CKD progression by 30–40% (CREDENCE trial).
  • Decrease glomerular hyperfiltration, improve fibrosis, and enhance renal oxygenation.
  • Initiated early in stages 1–3 CKD, even in non-diabetics with proteinuria.
• GLP-1 Receptor Agonists:
  • Agents like Rybelsus or dulaglutide offer cardiovascular and potential kidney benefits.
  • Reduce inflammation and oxidative stress; evolving data (e.g., FLOW trial for Rybelsus).
  • Used in obese diabetic patients to address multiple risk factors.
• Kerendia:
  • Targets aldosterone-driven fibrosis, a late-stage DKD feature.
  • Used in persistent albuminuria cases despite RAS blockade, slowing eGFR decline by 15–20%.

Microalbuminuria Screening and Early Intervention

• Screening Protocol:
  • Annual or biannual screening for microalbuminuria (>30 mg/g) in all diabetic patients.
  • Starts at diagnosis for type 2 diabetes or 5 years post-diagnosis for type 1.
• Intervention Approach:
  • Uses spot urine samples, with 24-hour collections for confirmation.
  • Intensifies RAS blockade, glycemic control, and lipid management if detected.

Lipid Management

• Strategy:
  • Utilizes Atorvastatin (10–20 mg) and Ezetimibe for lipid control.
  • Atorvastatin reduces LDL cholesterol and cardiovascular risk, with doses tailored to patient risk profiles.
  • Ezetimibe, added to statins, further lowers LDL-C and reduces atherosclerotic cardiovascular disease (ASCVD) events, especially in high-risk patients.
• Rationale:

• Targets LDL <70 mg/dL to mitigate cardiovascular events, a leading cause of death in DKD.

Lifestyle Optimization

• Dietary Specificity:

• Limits sodium (<2 g/day), refined sugars, and saturated fats.
• Maintains 0.8–1.0 g/kg/day protein in early DKD to avoid sarcopenia.

• Exercise Regimens:
  • Encourages 150 minutes/week of moderate aerobic activity (e.g., brisk walking) plus resistance training.
  • Tailors plans for frail patients to avoid overexertion.
• Smoking and Alcohol:
  • Provides cessation support (smoking doubles DKD risk).
• Limits alcohol to <14 units 30 ml each /week to prevent dehydration

Community Outreach and Screening

• Health Camps:
  • Conducted in Uttar Pradesh and Uttarakhand for high-risk diabetic populations.
  • Offers free eGFR tests, urine albumin checks, and education.
• Training Impact:
  • Trains local healthcare workers to recognize DKD signs.
  • Amplifies impact in resource-limited settings with scarce dialysis access.

Role of Keto Analogue Supplements in CKD

• Application:
  • Incorporated in advanced CKD (stages 2–5) to reduce protein catabolism and uremic toxins.
  • Provides essential amino acids with minimal nitrogen waste.
• Dosage and Monitoring:
  • Tailored at 0.1 g/kg/day based on residual renal function and nutritional status.
  • Monitors metabolic balance to preserve kidney function and delay dialysis.

Role of Pre-Probiotics in CKD

• Mechanism:
  • Improves gut microbiota health via the gut-kidney axis.
  • Reduces uremic toxins (e.g., indoxyl sulfate) from dysbiotic gut flora.
• Implementation:
  • Recommends strains like Lactobacillus and Bifidobacterium with prebiotic fibers.
  • Adjusts based on patient tolerance and lab markers to slow progression.

His Advocacy for Plant-Origin Proteins over Animal-Origin Proteins

• Preference:
  • Promotes plant-origin proteins (e.g., lentils, chickpeas) over animal-origin proteins (e.g., meat, dairy).
  • Lowers phosphorus and acid load, reducing kidney stress.
• Benefits:
  • Offers cardiovascular advantages and ensures adequate intake (0.6–0.8 g/kg/day in late CKD).
  • Collaborates with dietitians to avoid nutritional compromise.

Delaying Dialysis

Strategies for Preserving Residual Kidney Function (RKF)

• Focuses on meticulous medical management, complication prevention, and patient engagement.
• Targets CKD stages 3–5 (eGFR

Pharmacologic Optimization

• SGLT2 Inhibitors in Advanced CKD:
  • Continues low-dose SGLT2 inhibitors in stages 3b–4 (eGFR 15–45).
  • DAPA-CKD trial shows a 29% reduction in ESRD risk.
• RAS Blockade Continuation:

• Maintains ACEi/ARBs unless eGFR <15 or hyperkalemia is unmanageable.

• Diuretic Strategies:
  • Titrates loop diuretics (e.g., furosemide) for fluid overload.
  • Adds thiazides likeNatrilix Sr in resistant edema to preserve urine output.

Metabolic and Electrolyte Control

• Acidosis Management:
  • Uses oral sodium bicarbonate like Sodafix EC (500–1000 mg BID) to maintain bicarbonate at 22–26 mmol/L.
• Hyperkalemia Prevention:
  • Monitors potassium with dietary restrictions and binders (e.g.,K-Bind).
• Phosphorus and PTH:
  • Employs phosphate binders (e.g., Sevaneir) and calcitriollike Iwitrolanalogs early.

Dietary Fine-Tuning

• Protein Adjustment:
  • Reduces to 0.6–0.8 g/kg/day in stages 4–5, using high-biological-value sources.
• Fluid and Sodium Control:
  • Restricts fluid (1–1.5 L/day) and sodium (1.5–2 g/day) based on urine output.

Complication Management

• Anemia Correction:
  • Targets hemoglobin 10–11 g/dL with erythropoiesis-stimulating agents (e.g., darbepoetin).
• Infections:
  • Treats recurrent UTIs promptly with culture-guided antibiotics.
• Cardiovascular Vigilance:
  • Intensifies heart failure management with beta-blockers and monitors ischemic events.

Dialysis Modality Planning

• Proactive Preparation:
  • Plans fistula creation in stage 4 and educates on home hemodialysis or peritoneal dialysis.
• Timing Decision:
  • Assesses symptoms (e.g., uremia) in stage 5 rather than eGFR alone.

Psychological and Social Support

• Counseling:
  • Addresses anxiety and ensures regimen adherence with empathetic support.
• Resource Access:
  • Involves social workers to tackle financial and access barriers in India.

Stopping Dialysis

Challenges and Opportunities

• Exceptionally challenging due to negligible RKF (eGFR <5–10 mL/min/1.73 m²).

• Dr. Bhatt’s expertise in transplantation, AKI recovery, and optimization creates rare opportunities.

Residual Kidney Function Preservation

• Gentle Dialysis Prescriptions:
  • Uses incremental dialysis (1–2 sessions/week) or peritoneal dialysis.
  • Monitors RKF via 24-hour urine collections.
• Nephrotoxin Avoidance:
  • Avoids NSAIDs and contrast dyes to support minor RKF recovery.

Acute Kidney Injury Recovery

• Reversible Causes:
  • Identifies AKI triggers (e.g., dehydration, sepsis) via 500+ kidney biopsies.
  • Resolves obstructions or treats glomerulonephritis with immunosuppressants.
• Monitoring:
  • Uses serial eGFR, urine output, and biomarkers (e.g., NGAL, KIM-1) for withdrawal trials.

Kidney Transplantation

• Pre-Emptive and High-Risk Transplants:
  • Experience of 1,000+ transplants, including ABO-incompatible cases.
  • Prioritizes living donors for 85–90% 5-year graft survival.
• Desensitization Protocols:
  • Uses plasmapheresis, IVIG, rituximab, and Daratumumab.
• Post-Transplant Care:
  • Optimizes immunosuppression (e.g., tacrolimus) and monitors for rejection.

Trial of Dialysis Cessation

• Criteria:
  • Attempts cessation if urine output >1 L/day and eGFR improves to 10–15 mL/min/1.73 m².
• Management:
  • Conducts weekly labs (creatinine, urea, electrolytes).
  • Uses diuretics and binders with patient education.
• Feasibility:

• High-risk, viable in <5% of cases per nephrology literature.

• • Regenerative and Experimental Therapies

• Stem Cell Therapies:
  • Refers patients to trials (e.g., mesenchymal stem cells) for CKD repair.
• Bioartificial Kidneys:
  • Engages with innovations like the Kidney Project.

Holistic Recovery Support

• Stability Measures:
  • Integrates physiotherapy, nutritional support, and psychological care.
• Comorbidity Management:
  • Aggressively treats diabetes and hypertension post-dialysis.

Unique Aspects and Innovations

• Transplant Expertise: Proficient in complex cases (1,000+ transplants).
• Biopsy-Driven Precision: 500+ biopsies for targeted therapies.
• Rural Outreach: Health camps detect DKD early in underserved areas.
• Patient Rapport: Simplifies concepts (e.g., eGFR) to boost compliance.
• Research Integration: 12+ international publications adopt therapies like Kerendia and SGLT2 inhibitors early.

Challenges and Limitations

Preventing CKD

• Late presentation limits preventive impact despite camps.
• High costs of SGLT2 inhibitors and Kerendia restrict access.
• Compliance issues due to low health literacy or depression.

Delaying Dialysis

• Limited leeway in stage 5 CKD due to uremic symptoms.
• Comorbidities (e.g., heart failure) accelerate progression.
• Resource constraints may force early initiation.

Stopping Dialysis

• Rare cessation outside transplantation due to CKD irreversibility.
• Transplantation risks (10–15% rejection) and resource-intensive trials.

Scientific and Clinical Context

• DKD Pathophysiology: Hyperglycemia causes glomerular damage and fibrosis.
• SGLT2 Impact: 30–40% ESRD risk reduction (DAPA-CKD, CREDENCE).
• Transplant Outcomes: 90–95% 1-year graft survival in India.
• RKF Importance: 20–30% mortality reduction (NECOSAD).

Conclusion

• Dr. Anil Prasad Bhatt’s strategies for CKD prevention in diabetics rely on early detection, aggressive risk control, and therapies like Lipaglyn, IMEG-CKD, SGLT2 inhibitors, and Kerendia.
• Lipid management with Atorvastatin (10–20 mg) and Ezetimibe reduces cardiovascular risk.
• Delaying dialysis involves preserving RKF with medical and lifestyle management.
• Stopping dialysis is achieved mainly through transplantation, with rare successes in AKI recovery.
• His holistic approach sets a high standard, offering hope despite patient and systemic challenges.

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