Nephropathy

Question 1

what is diabetic nephropathy?

Answer 1

Kimmelsteil- wilson syndrome/ nodular glomerulosclerosis
progressive kidney disease caused by damage to the capillaries in the glomeruli in the kidneys, characterised by proteinuria and diffuse scarring of the glomeruli

Question 2

what is the most common cause of kidney failure/dialysis in the UK?

Answer 2

diabetes

Question 3

what are the consequences of diabetic nephropathy?

Answer 3

development of hypertension
decline in renal function (reduction in GFR of 1ml/min/month if untreated)
accelerated vascular disease
if chronic kidney disease secondary to diabetes the risk of dying is greatly increased

Question 4

what is nephropathy defined by?

Answer 4

The basis of urine protein, neuropathy can be divided into insipient nephropathy and overt neuropathy

Question 5

what is ACR?

Answer 5

albumin creatinine ration (units = mg alb/mmol creat)

Question 6

what is PCR?

Answer 6

protein to creatinine ratio

Question 7

which is smaller ACR or PCR

Answer 7

albumin is a component of total protein therefore ACR smaller than PCR (ACR is a fraction of PCR)

Question 8

when to test for ACR and PCR?

Answer 8

if urine dipstick +ve for glucose and protein

Question 9

normal ACR

Answer 9

<3.5 in females

<2.5 in males

Question 10

microalbuminuria

Answer 10

ACR <30
PCR <50
repeat twice if 2/3 +ve then confirmed (incipitent neuropathy)

Question 11

proteinuria

Answer 11

ACR >30
PCR>50
repeat on EMU - early morning urine
overt nephropathy

Question 12

what causes the urinary albumin excretion rate to vary?

Answer 12

dat/night
exercise
protein load
fluid load

Question 13

what can cause a false +ve for microalbuminuria?

Answer 13

menstruation 
vaginal discharge 
UTI
pregnancy 
other illness 
non-diabetic renal disease

Question 14

how do you interpret urine protein measures?

Answer 14

measure PCR and multiple by 10 (assuming daily creatinine excretion is 10mmol)

Question 15

how is nephropathy screened for?

Answer 15

all patients with diabetes should have urinary albumin conc. (using a random urine sample) and serum creatinine measured at diagnosis and at regular intervals (usually annually)
ACR should be measured using a laboratory method or near-patient test specific for albumin at low conc.
an abnormal result should be confirmed by a further 1st pass (first morning urine) sample without delay

Question 16

why is microalbuminuria screened?

Answer 16

because it is a marker of high risk of high risk for nephropathy

Question 17

how is it treated?

Answer 17

ACEi/ARB
SGLT2i should be given to everyone with T2DM and kidney disease
in all patients with DM BP should be maintained at <140/80