Diabetic nephropathy

Question 1

How can you make a clinical diagnosis of diabetic nephropathy?

Answer 1

1. long-standing diabetes (>10 years)
2. with albuminuria
3. and/or reduced estimated glomerular filtration rate (eGFR) in the absence of signs or symptoms of other primary causes of kidney damage

Question 2

How is the diagnosis of diabetic nephropathy conclusively made?

Answer 2

mesangial expansion and nodular glomerloscleroris on kidney biopsy (rarely needed)

Question 3

How common is it to develop diabetic nephropathy?

Answer 3

• 20% to 40% of patients with type 1 or type 2 diabetes mellitus develop DKD
• Common cause of CKD

Question 4

What are the RF for diabetic nephropathy?

Answer 4

1. Sustained hyperglycaemia
2. Hypertension
3. Fhx hypertension/kidney disease
4. Obesity
5. Smoking

Question 5

What are the symptoms and signs of diabetic nephropathy?

Answer 5

1. Hypertension
2. Signs or retinopathy
3. Oedema
4. Numbness lower extremities
5. Poor vision
6. Foot changes

Question 6

What is DDx for diabetic nephropathy?

Answer 6

1. Non-diabetic kidney disease
2. Multiple myeloma
3. Renal tract obstruction
4. Glomerulonephritis
5. Renal artery stenosis

Question 7

What investigations are used for diabetic nephropathy?

Answer 7

1. Urinalysis
2. Urinary albumin to creatinine ratio (ACR)
3. Serum creatinine with GFR estimation
4. Kidney US

Question 8

What would urinalysis show in diabetic nephropathy?

Answer 8

proteinuria

Question 9

What may the urinary albumin to creatinine ratio (ACR) show in diabetic nephropathy?

Answer 9

increased alumin 30-300mg/g

Question 10

What would serum creatinine with GFR estimate show in diabetic nephropathy?

Answer 10

GFR may be raised in CKD stage 1, normal in CKD stage 2, and reduced in CKD stages 3-5

Question 11

What would kidney US show in diabetic nephropathy?

Answer 11

normal to large

Question 12

What is the management plan for diabetic nephropathy?

Answer 12

-1st line: glycaemic control
-Plus: ACE inihibitor or Angiotensin receptor blocker
Statin
If BP not controlled: CCB

Question 13

What are possible complications of diabetic nephropathy?

Answer 13

1. End stage renal disease
2. Hyperkalaemia
3. Cardiovascular events
4. Blindness
5. Peripheral vascular disease
6. Anaemia

Question 14

How does DKD compare to normal CKD?

Answer 14

DKD worse complication, performance on dialysis and worsening proteinuria than other CKD - but managed DM

Question 15

What is the gold stanrd investigation for diabetic nephropathy?

Answer 15

Renal biopsy showing Kimmelstiel-Wilson nodules (rarely done in practice)

Question 16

What is diabetic neurorahty caused by?

Answer 16

1. Diabetes is commonest cause of neuropathy

2. Caused by blockage of vasa nervorum

Question 17

What is peripheral neuropathy?

Answer 17

1. “glove and stocking distribution”
2. Loss of sensation (particularly feet)
3. May not sense injury to foot

Question 18

How can you inspect peripheral neuropathy?

Answer 18

1. INSPECT FEET!
2. Monofilament on lower limb exam
3. Loss of ankle jerk/vibration sense/fractures (Charcot’s joint)

Question 19

What is mononeuropathy?

Answer 19

Sudden motor loss usually

Question 20

What is an example of mononeuropathy?

Answer 20

wrist drop, foot drop, 3rd nerve palsy (eye down and out, pupil responds to light)

Question 21

What is autonomic neuropathy?

Answer 21

1. GI tract: difficulty swallowing, delayed gastric emptying, bladder dysfunction
2. Postural hypotension (collapse on standing)
3. Cardiac autonomic supply