renal medicine,

Diabetic Nephropathy

Sep 13, 2020

Key facts

  • The commonest cause of chronic kidney disease and end-stage renal failure
  • Pathophysiology
    • Hyperglycaemia leads to ↑growth factors, renin-angiotensin-aldosterone activation, production of advanced glycosylation end-products, and oxidative stress
    • Causes ↑glomerular capillary pressure, podocyte damage, and endothelial dysfunction
  • Albuminuria is first clinical sign
  • Later scarring (glomerulosclerosis), nodule formation (Kimmelstiel-Wilson lesions), and fibrosis with progressive loss of renal function made worse by ↑BP

Diagnosis

  • Microalbuminuria; ACR 3–30mg/mmol (not detected on standard dipstick)

Management

  • Intensive BM control
    • Aim Hba1c of <53mmol/mol (<7%)- ↓microvascular complications
  • BP <130/80- for CV and renal protection
    • 1st line: ACE-I or ARB for CV and renal protection
    • Add CCBs and/or Thiazide-like diuretic
  • Sodium restriction to <2g/day
  • Statins to ↓CV risk
  • Screen for ACR annually