Diabetes and Kidney

Question 1

Definition

Answer 1

Diabetic kidney disease (DKD) is defined by albuminuria (increased urinary albumin excretion is defined as ≥3.4 mg/mmol [30 mg/g]) and progressive reduction in glomerular filtration rate (GFR) in the setting of a long duration of diabetes (>10 years’ duration of type 1 diabetes; may be present at diagnosis in type 2 diabetes), and is typically associated with retinopathy.

Question 2

RF

Answer 2

• Sustained hyperglycaemia
• Hypertension
• FH
• Obesity
Smoking

Question 3

Ddx

Answer 3

Non-diabetic kidney disease

rapid progression of renal failure, evidence of another systemic disease, or short duration of diabetes , serology

Multiple myeloma

Bone pain, anaemia, hypercalcaemia, paraprotein, lytic bone lesions,

Renal tract obstruction

Urinary signs, tenderness, US, high PSA, relief on catheter

Glomerulonephritis

Signs of systemic disease, urinalysis, serology, biopsy

Renal artery stenosis

ACEi or ARB, bruits, US

Question 4

A?

Answer 4

poor control of DM

Question 5

P?

Answer 5

• Kidney damage caused by T1 and T2 DM
• Many nephrons inside a kidney and each have a glomerulus, with an afferent and efferent arteriole-supported by mesangial cells
• Blood filtered through capillary, basement membrane, epithelial podocytes-filtrate via slits
• Membrane repels albumin
• Excess glucose-can’t be absorbed so removed in urine
• Non-enzymatic glycation-involves basement membrane and efferent arteriole-stiffens (hyaline arteriosclerosis)
• This causes obstruction to blood flow whcih increases the pressure causing dilation and increases flow and pressure
• -increased GFR-hyperfiltration
• Mesangial cells secrete more matrix-thicker glomerulus -Kimmelstiel-Wilson nodules of protein
• The thickening makes it more permeable-gaps increase too-disruption of podocytes
• This disrupts the membrane-decreased GFR
• More symptoms are more nephrons are affected-progresses to end-stage renal disease

Question 6

I?

Answer 6

• Urinalysis-proteinuria
• ACR-Microalbuminuria (‘moderately increased albuminuria’) =a:cr3–30mg/mmol
• Serum creatinine and GFR estimation
• KUS-normal-to-large kidneys with increased echogenicity; may show hydronephrosis if vesiculopathy

Question 7

M?

Answer 7

• •Intensivedmcontrol prevents microalbuminuria and reduces risk of progression to macroalbuminuria (‘severely increased albuminuria’) =a:cr>30mg/mmol. Hba1cof 53mmol/mol (7%) reduces the development of all microvascular complications. However, less impact oncvdrisk and hard renal outcomes including progression to kidney failure. Consider risk of hypoglycaemia.
• •bp<130/80. Useace-i orarbforcvand renal protection abovebpcontrol. Can prevent progression from normoalbuminuria to microalbuminuria to macroalbuminuria in hypertensivedm. (Less clear benefit in normotensivedmbut recommended ifa:cr>30mg/mmol.) No head-to-head studies oface-i/arbindmbut equivalence outsidedm. If cough withace-i switch toarb. No benefit to dual therapy and ↑risk of ↑K+. Data on direct renin inhibitors (eg aliskiren) awaited.
• •Sodium restriction to <2g/day (=<5g sodium chloride/day).
• •Statins to reducecvrisk (p[link]). Unclear benefit once on dialysis: do not initiate but do not need to discontinue if tolerated.

Question 8

prognosis?

Answer 8

• Delayed if treat hyperglycaemia, hypertension and dyslipidaemia.
Can progress to renal failure

Question 9

Complications?

Answer 9

• End stage renal disease
• Hyperkalaemia
• CVD
• Blindness
• PVD
• Refractory hypertension
• Bone disease
• Anaemia
hypoglycaemia

Question 10

CP?

Answer 10

• Often asymptomatic; patients may complain offoamyurine
• Progressivediabetic kidney diseasewith signs ofrenal failureand risk ofuremia(e.g., uremicpolyneuropathy)
• Arterialhypertension