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Diabetic Nephropathy

  • MCC of end stage kidney disease
    • Decrease insulin → hyperglycaemia → HTN + kidney dysfunction → kidney failure

Stages of diabetic nephropathy

  • 1 – early stage, normal GFR
  • 2 – microalbuminuria
  • 3 – clinical proteinuria
  • 4 – Nephrotic syndrome + HTN
  • 5 – renal impairment
  • 6 – end stage renal failure

Pathophysiology

  • ↑Pressure state – due to DM (HTN)→ ↑GFR
    • ↑BP → ↑flow through glomerulus → mesangial expansion
      • Mesangial expansion – high pressure results in damage of mesangium
        • Cells secrete cytokines → inflam and O2 radicals → endoth dysfunction → hypertrophy + matrix accumulation
    • When mesangium expands, space between podocytes exands – decreased surface area for filtration
    • Filtration system is leaky – microalbuminuria (30-300mg/24h) and proteinuria
  • Nephron ischemia – decreased GFR
    • Blood supply to lobule of nephron is from vasoconstriction of efferent arteries due to activation of RAAS – this decreases over time → ischemia → atrophy

Clinical features

  • Severe tiredness, headaches, N+V, loss of app, itchy skin, leg swelling

Diagnosis

  • Renal hypertrophy, glomerular lesions ( KW lesions )
  • Microalbuminuria, proteinuria, glom hyperfiltration, progressive loss of GFR
  • Screening – urine albumin:creatinine ratio
  • USS – hypertrophy

Treatment

  • Treat DM (keep HbA1c <7% and LDL <3.0)
  • Microalbuminuria – ACEI + ARBs
    • Decrease intraglomerular pressure and therefore decrease proteinuria
  • End stage renal disease – dialysis + transplant

Complications

  • Neurogenic bladder, renovascular disorders, papillary necrosis, FSGS
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