Microvascular complications and the kidney: Diabetic nephropathy

Question 1

What are the characteristics of diabetic nephropathy

Answer 1

1. Hypertension
2. Progressively increasing proteinuria
3. Progressively deteriorating kidney function
4. Histological features

Question 2

Why is diabetes and CKD so important

Answer 2

It massively increases the risk of cardiovascular events

Question 3

What glomerular changes might you see in diabetic nephropathy

Answer 3

Mesangial expansions

Basement membrane thickening

Glomerulosclerosis

Question 4

What proportion of patients with type 1 diabetes needed dialysis after how long

Answer 4

Type 1 DM : 20-40% after 30-40 years

Question 5

What proportion of patients with type 2 diabetes need dialysis. Is it less than type 1?

Answer 5

Before we thought is was less, but probably because lots of type II diabetics were dying before they got this.

Now they are living longer, the number of type II diabetics needing dialysis is increasing all the time. So the risk is probably similar to T2DM.

Question 6

Which factors are important in diabetic nephropathy

Answer 6

1. Age of development of disease
2. Racial factors
3. Age at presentation
4. Loss due to cardiovascular morbidity

Question 7

Clinical features of diabetic nephorpathy

Answer 7

Progressive proteinuria

Increased BP

Deranged renal function

Question 8

Classify proteinuria

Answer 8

Normal: <30mg/24hrs

Microalbuminuric: 30-300mg/24hrs

Assymptomatic: 300-3000/24hrs

Nephrotic: >3000mg/24hr

Question 9

Strategies for intervention in diabetic nephropathy

Answer 9

Diabetic control

Blood pressure control

Inhibition of activity of the RAS system

Stopping smoking

Question 10

T/F reducing BP can reverse the renal effects of diabetes

Answer 10

F…. it just causes the GFR to fall at a slower rate

Question 11

What happens to the creatinine with days of starting ACEi?

Answer 11

It actually gets worse (worse than it would be if you hadn’t given the ACEi!)

This is because it vasodilates the efferent arteriole, reducing the pressure in the glomerulus and thus the GFR.

Question 12

t/f ACEi reduces microalbuminuria

Answer 12

T. Because it reduces the pressure in the glomerulus, less proteins are forced out

Question 13

ACEi reduces eGFR a bit in the short term compared to if they hadn’t been given an ACEi but in the long term it protects them from end stage renal failure because it causes GFR to fall much more gradually

Answer 13

….

Question 14

What is a contraindication of ACEi

Answer 14

Renal artery stenosis

Question 15

What do you need to do if you give ACEi to a patient with renal artery stenosis

Answer 15

STOP the ACEi immediately.

Contact renal doctors who might need to dialyse them.

Question 16

Name a reversible cause of anuria

Answer 16

Giving ACEi to a patient with renal artery stenosis