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Diabetic nephropathy

Medicine > Endocrine & metabolic

Background Knowledge 🧠

Definition

  • Diabetic nephropathy is a progressive kidney disease caused by damage to the capillaries in the kidneys’ glomeruli due to longstanding diabetes mellitus.
  • It is characterised by albuminuria, declining glomerular filtration rate (GFR), and increased risk of cardiovascular morbidity and mortality.

Epidemiology

  • Affects approximately 20-40% of patients with diabetes.
  • Leading cause of end-stage renal disease (ESRD) in the UK.
  • More common in Type 1 diabetes but also significant in Type 2 diabetes.

Aetiology and Pathophysiology

  • Hyperglycaemia leads to glomerular hyperfiltration and hypertension, causing damage to glomerular capillaries.
  • Advanced glycation end products (AGEs) and increased oxidative stress contribute to renal damage.
  • Genetic predisposition may play a role.
  • Persistent albuminuria (≥300 mg/day) is a key marker.

Types

  • Early-stage diabetic nephropathy: Microalbuminuria (30-300 mg/day).
  • Advanced-stage diabetic nephropathy: Macroalbuminuria (≥300 mg/day).
  • End-stage renal disease (ESRD): Significant decline in kidney function requiring dialysis or transplantation.

Clinical Features 🌡️

Symptoms

  • Often asymptomatic in early stages.
  • Peripheral oedema.
  • Fatigue and weakness.
  • Nausea and vomiting in advanced stages.
  • Loss of appetite.
  • Foamy urine due to proteinuria.

Signs

  • Hypertension.
  • Proteinuria detected on dipstick testing.
  • Raised serum creatinine and urea.
  • Reduced eGFR.
  • Signs of underlying diabetes (e.g. retinopathy).

Investigations 🧪

Investigations

  • Urine albumin-to-creatinine ratio (ACR): Preferred method for detecting albuminuria.
  • Serum creatinine and eGFR: To assess kidney function.
  • Blood pressure is often elevated.
  • Retinal examination: To check for diabetic retinopathy.
  • Blood tests: HbA1c to monitor glucose control.
  • Renal ultrasound: To rule out other causes of kidney disease.

Management 🥼

Management

  • Optimal glycaemic control (target HbA1c ≤ 7%): metformin is first-line for Type 2 diabetes.
  • Blood pressure control (target <130/80 mmHg): ACE inhibitors or ARBs are preferred.
  • Management of dyslipidaemia through statins.
  • Dietary modifications: Low sodium and protein intake.
  • Regular monitoring of renal function and albuminuria.
  • Referral to nephrologist if rapid progression or severe disease.

Complications

  • End-stage renal disease (ESRD).
  • Cardiovascular diseases.
  • Acute kidney injury.
  • Infections due to immunosuppression.
  • Electrolyte imbalances.

Prognosis

  • Depends on the stage at diagnosis and effectiveness of management.
  • Early intervention can slow progression.
  • Poor glycaemic and blood pressure control associated with worse outcomes.
  • ESRD typically requires dialysis or renal transplantation.
  • Increased mortality risk due to cardiovascular complications.

Key Points

  • Regular screening for microalbuminuria is crucial.
  • Maintain optimal blood glucose and blood pressure levels.
  • Use ACE inhibitors or ARBs in patients with albuminuria.
  • Monitor renal function periodically.
  • Early referral to nephrology can improve outcomes.

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Endocrine & metabolic