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Year 3 > Diabetic nephropathy (E&M) > Flashcards

Diabetic nephropathy (E&M) Flashcards

1
Q

Define diabetic nephropathy (AKA diabetic kidney disease).

A

Defined by albuminuria and progressive reduction in eGFR in the setting of long-standing diabetes (>10 years)

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2
Q

What is diabetic nephropathy the most common cause of?

A

CKD

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3
Q

How many patients develop diabetic nephropathy?

A

20-40% of patients with either T1DM/T2DM

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4
Q

What major histological changes do you see in diabetic nephropathy? (3)

A
  • mesangial expansion
  • glomerular basement membrane thickening
  • glomerulosclerosis
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5
Q

What is diabetic nephropathy dependent on?

A

The extent and duration of hyperglycaemia and hypertension

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6
Q

What pattern is becoming more common in diabetic nephropathy?

A

Reduced eGFR without albuminuria

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7
Q

What are the clinical features of diabetic nephropathy? (7)

A
  • hypertension
  • oedema of extremities (in advancing disease)
  • claudication
  • polyuria
  • lethargy / fatigue
  • anorexia
  • signs of retinopathy - blot haemorrhages, microaneurysms, neovascularisation
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8
Q

What are the signs of diabetic nephropathy? (4)

A
  • hypertension
  • oedema
  • findings of associated microvascular complications - retinopathy, neuropathy
  • signs of clinical uraemia
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9
Q

What are the features of clinical uraemia as seen in diabetic nephropathy? (7)

A
  • anorexia
  • encephalopathy
  • N&V
  • dysgeusia (foul taste in mouth)
  • bleeding
  • myoclonus
  • pericarditis
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10
Q

What are the risk factors for diabetic nephropathy? (7)

A
  • sustained hyperglycaemia
  • hypertension
  • Fx CKD
  • obesity
  • smoking
  • physical inactivity
  • dyslipidaemia
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11
Q

What are the first-line investigations for diabetic nephropathy? (4)

A
  • urinalysis
  • urinary ACR
  • serum creatinine with GFR estimation
  • kidney ultrasound
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12
Q

What is the characteristic lab finding (along with reduced eGFR) in diabetic nephropathy?

A

Proteinuria on urinalysis (1st-line)

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13
Q

What might urinary ACR show in diabetic nephropathy?

A
  • moderately-increased albuminuria (microalbuminuria): 30-300mg/g
  • severely-increased albuminuria (macroalbuminuria): >300mg/g
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14
Q

How often do patients need to be screened for urinary ACR in diabetes?

A

Annually

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15
Q

What might you see on serum creatinine with GFR in diabetic nephropathy?

A

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

I.e. GFR raised in early disease but reduced in late disease

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16
Q

What might you see on kidney USS in diabetic nephropathy?

A
  • normal-to-large kidneys with increased echogenicity
  • may show hydronephrosis if vesiculopathy and/or obstruction is superimposed
17
Q

What is the gold-standard investigation for diabetic nephropathy? (1 + 4)

A

Renal biopsy:

  • Kimmelstiel-Wilson nodules
  • mesangial expansion
  • GBM thickening
  • glomerulosclerosis
18
Q

What are some differential diagnoses for diabetic nephropathy? (5)

A
  • non-diabetic kidney disease
  • multiple myeloma (renal failure, proteinuria, bone pain, anaemia)
  • renal tract obstruction
  • glomerulonephritis (signs of systemic disease e.g. rashes/joint involvement, haematuria)
  • renal artery stenosis (refractory hypertension/renal failure shortly after initiating ACEi/ARB)
19
Q

What is the management plan for diabetic nephropathy? (6)

A
  • glycaemic control
  • hypertension - ACEi/ARB –> CCB/TLD+/-BB
  • dietary modification - reduce protein and salt intake
  • lipid control - statin (atorvastatin) +/- ezetimibe (recent ACS)
  • in T2DM: non-steroidal mineralocorticoid receptor antagonist - finerenone
  • consider pancreas-kidney transplantation
20
Q

When do you consider pancreas-kidney transplantation in diabetic nephropathy? (3)

A
  • if they do not have significant insulin resistance
  • C-peptide>2 and BMI<30
  • recipients must have a GFR<20mL/min/1.73m2 or be dialysis-dependent
21
Q

What do you give a diabetes patient the second they present with microalbuminuria?

A

ACEi

22
Q

What are some complications of diabetic nephropathy? (9)

A
  • end-stage renal disease
  • hyperkalaemia
  • cardiovascular events
  • blindness
  • peripheral vascular disease
  • anaemia
  • refractory hypertension
  • bone disease
  • hypoglycaemia
23
Q

Describe the prognosis of diabetic nephropathy.

A

Morbidity and mortality can be avoided/delayed with intensive treatment of hyperglycaemia, hypertension and dyslipidaemia and with careful attention to diet and avoidance of nephrotoxic agents

Year 3 (148 decks)

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