Diabetic Nephropathy Flashcards
4 factors anbout diabetes that lead to kidney disease
- advanced glycosylation end products
- hyperfiltration
- RAAS activation
- Metabolic syndrome risk factors like ypertension, obesity, dyslipidemia
how does advanced glycosylation cause kidney disease
high levels of serum glucose that get glycosylated, which activate the mechanisms of fibrosis and scarring in the kidneys
2 broad groups that encapsule chronic kidney disease in diabetes
- diabetic nephropathy
- other disease caused by the metabolic syndorme risk factosr
diabetic nephropathy age of onset
diabetes for at least 10 years
specific pathological histology signs of diabetic nephropathy
- mesangial expansion
- basement membrane thickening
- kimmelstiel wilson nodules
recall that kidney disease chronic in diabetes is made up of 1. diabetic neprhopathy and 2. other diseases caused by metabolic syndrome risk factors. what are the two other diseases in the “other” category
- hypertensive nephrosclerosis
- large vessel ischemic nephropathy
- both have different prognoses and treatment.
random kidney disease
Any kidney disease unrelated to diabetes or its risk factors
in type 1DM, diabetic neprhopathy takes ___ years to develop. what about in type II?
T1DM: 10 years to develop
T2DM: at any time.
natural history is key to diagnosis.
explain how albumin and GFR changes in diabetic neprhoapthy
Albuminuria rises into the stage A3 range before GFR decline.
- other end organ complications are usually present
- gfr incrases in pre-neprhopahty stage, and then declines over time. Albumin increases the entire time, until it reaches A3 >300mg/day, correlating with na ACR of over 30 mg/mmol. GFR declines rapidly after A3 stage.
how can you differentiate hypertensive nephrosclerosis and large vessel ischemic nephropathy vs DIABETIC NEPHROPATHY?
THEY DO NOT PRESENT WITH ALBUMINURIA
GFR decliens WITHOUT albuminuria rising.
if someone has declline in GFR without albuminuria, most likely not diabetic neprhopathy. they may also not have other end organ signs of diabetes (like retinopathy)
Other main causes of chronic kidney disease are hypertensive nephrosclerosis and large vessel ischemic nephropathy. Characterized by CKD without ____ or end organ signs of ___
Other main causes of chronic kidney disease are hypertensive nephrosclerosis and large vessel ischemic nephropathy. Characterized by CKD without proteinuria or end organ signs of diabetes
- in diabetes nephropathy, the person has diabetes and has higher albuminuria with other end organ changes.
random kidney diseases are diseases that aren’t due to diabetes or their risk factors leading to diabetes. how can you tell if someone has a random kidney disease?
red flags are present:
`. persistent hematuria or active urine– diabetic neprhoapthy does not have hematuia
- rapidly falling eGFR- in DN, gfr changes very slowly through their life.
- signs or symtoms of systemic illness
- very high amoutns of proteinuria
- no or few complications of diabetes
- known duration of diabetes UNDER 5 YEARS – DM-N starts 10 years
- family history of non-DM kidney disease.
When should you screen for kidney disease in T1 vs T2 DM. What tests do you run?
type 1: after 5 years
type 2; upon diagnosis.
- creatinine urinalysis, ACR, screen annually
outline the screening process (findings of ACR or eGFR)
If ACR > 3mg/mmol or eGFR <60 ml/min repeat eGFR in 3 months and 2 more ACRs
If ACR is high on 2/3 then CKD
If GFR stays low then CKD
If ACR >20 mg/mmol then CKD
THESE TESTS DO NOT DISTGINSUIHS THE TYPE OF KIDNEY DISEASES IN TYPE I DM–YOU MUST RULE OUT RANDOM KIDNEY DISEASES BY LOOKING AT THE 6 RED FLAGS
does this person have DMN
no. hypertensive neprhosclerosis. there is no albuminuria.
Diabetic Nephropathy
Long standing diabetes
End organ signs Albuminuria
Remember GFR doesn’t have to be low.
Albuminuria alone can make a diagnosis.
DMN?
NO. DMN does not have blood and protein on urinalysis. hematuria is a red flag for a random kidney disease. likely glomerulonephritis.
- further work up is urgently required.
___ ___ ___ is the conerstone of therpay
BLOOD SUGAR CONTROL.
- tight blood sugar control has been shown a reduction in kidney disease. some damage may be reversibly even, indicating a LEGACY EFFECT; early control reduces complicatiosn in the long term.
how does diabetes affect the RAAS system
RAAS activation
how can hyperfiltration be treated to reduce kidney disease in diabetes
- hyperfiltration can cause kideny damage.
- ACE inhibitors and ARBS will suppress tthe RAS system by reducing the maount of angiotensin 2 activation. they will also DILATE THE EFFERENT ARTERIOLE.
- it’s been shown that kidney disease risk is reduced by 50%.
- all patients with diabetes and CKD should be on one.
T/F you can combine ACE and ARBs
false. there is an increased risk of AKI. often because of ischemia due to reduced blood flow.
in addition to ARBS/ACe, what is another med that can reduce hyperfiltartion
SGLT2 inhibitors. blocks glucose absorption and sodium at the pCT. more sodium is delivered to thick ascending loop of henle. leads to afferent vasoconstriction. with less blood going to the glomerulus, the amount of hyperfiltration will decrease.
- indicated in TYPE2DM ACR >30 mg/mmol OR GFR >30ml/min (preserved GFR and albuminuria)
T/F you can give SGLT2 inhibitors to people with type I DM.
false. it can increase the risk of DKA
non pharmacological management of diabetic nephropathy
BLOOD PRESSURE MONITORING. BP <130/80 reduces the risk of CKD
