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Diabetic Nephropathy
(Diabetic Kidney
disease)
Diabetic kidney disease.
 |
Diabetic Kidney disease is a
major cause of disability and premature death, in diabetic patients. | |
It is a multistage condition
that requires many years before becoming clinically overt (clinically
manifested) | |
Moderate renal impairment (microalbuminuria)
in a NIDDM (Non Insulin Dependent Diabetes Mellitus) is associated with a marked
increase in cardiovascular death, or disability and poor quality of life. |
Stages of diabetic kidney diseases:
-
Incipient
nephropathy (sub clinical-not manifested clinically).
-
Clinical
(overt) nephropathy.
-
Advanced
nephropathy.
-
End
stage renal disease.
Incipient nephropathy (sub clinical-not manifested clinically):
|
Defined as the stage of a
persistent increase above normal in the urinary albumin excretion rate, also
known as microalbuminuria, in the absence of frank proteinuria (dipstick positive). May
be accompanied by hypertension. | |
Incipient diabetic nephropathy (diabetic micro
albuminuria)
should only be diagnosed when seen to be present on repeat testing
and when other causes of raised urinary albumin have been
excluded.
|
Clinical (overt) nephropathy:
|
Defined as the presence of
persistent proteinuria (>200ug/minute or >300mg/24 hours); and is usually
accompanied by hypertension. |
Advanced nephropathy:
|
In advanced nephropathy,
there is a significant deterioration of renal function, with a severe decline in
GFR (Glomerular filtration rate of kidneys) and the appearance of symptoms of
uremia (symptoms due to rise in blood levels of toxic substances not excreted by
failing kidneys) and /or nephrotic syndrome (generalized swelling in body) |
End stage renal disease:
|
This stage necessitates
dialysis or renal transplant. |
Microalbuminuria.
|
Incipient
nephropathy is the stage of microalbuminuria; | |
Microalbuminuria
is defined as albumin (one of the proteins) excretion rate: |
-
between
30-300 mg per 24 hours, or
-
an
albumin excretion rate exceeding 20 ug/minute and less than 200 ug/minute.
Testing
for microalbuminuria should be:
|
Done
at the time of diagnosis in all patients and at yearly intervals thereafter. | |
Done
only if urine is dipstick negative. | |
If
negative, repeat annually. | |
If
positive, rule out other causes of raised urinary albumin excretion,
and confirm ,by rechecking 2-3 times within a 6 months period. |
Methods
for testing urinary albumin excretion.
Albumin
excretion can be estimated through the following methods:
-
24
hours urine collecting.
-
Timed
collection, say over a period of 4 hours.
-
Spot
urinary sample.
The results are analyzed as follows:
|
|
24 hour collection
|
Timed collection
|
Spot collection
|
|
|
mg / 24 hours
|
ug / min
|
ug/mg Creatinine
|
|
Normal
|
<30
|
<20
|
<30
|
|
Microalbuminuria
|
30-300
|
20-200
|
30-300
|
|
Clinical Albuminuria
|
>300
|
>200
|
>300
|
 |
Urinary albumin excretion (UAE) has a marked
intra-individual day to day variation which may be up to 50%
thus, in patients with an increase in the urinary albumin
excretion rate, or a persistent proteinuria, the UAE should be
measured in sterile urine on 3 different intervals over a 4-6
month period;
| |
Other condition which lead to an increase in UAE should be
ruled out; more than 30% patients with raised UAE and/or
persistent proteinuria may have an extra renal cause;
|
Note:
If incipient / clinical diabetic nephropathy is confirmed
perform renal function test (Serum
Creatinine,
urea etc.) and proceed as
follows:
-
Serum
Creatinine normal or slightly raised :
repeat
renal tests every 4-6 months.
-
Serum
Creatinine moderately raised :
initiate joint
care with renal team.
-
Serum
Creatinine significantly raised :
prompt referral
to renal team.
Diabetes and Kidney Disease
 |
A patient who has diabetes runs a greater risk of developing kidney disease,
especially if the diabetes started before the patient was 20 years old. | |
Diabetes
can cause vascular changes that can affect the kidneys' function; they become
less and less able to process and metabolize carbohydrates, proteins, fats, and
insulin. | |
The level of kidney function usually decreases gradually until the
kidneys stop functioning altogether. |
To help prevent the loss of kidney function,
|
It is important that you prevent
high blood pressure and maintain good control of your blood sugar level. | |
The
more your blood sugar level fluctuates, the harder your kidneys have to work. | |
Keep your blood sugar at the level that your doctor prescribes, and you will
help slow kidney deterioration. |
Management
of nephropathy
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