Endocrinology Book

Diabetes Mellitus

  • Diabetic Nephropathy

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Diabetic NephropathyAka: Nephropathy of Diabetes Mellitus

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  1. Pathophysiology: Nephropathy progression
    1. Step 1: Incipient Nephropathy phase
      1. Microalbuminuria (low levels of albumin) present
      2. Urine Albumin levels gradually rise during this phase
    2. Step 2: Overt Nephropathy phase
      1. Urine Albumin >300 mg/24 hours
      2. Hyperfiltration transiently occurs
        1. Glomerular filtration (Creatinine Clearance) rises
    3. Step 3: Renal Insufficiency
      1. Glomerular filtration (Creatinine Clearance) falls
      2. Ultimately Renal Failure ensues
  2. Monitoring
    1. Monitor for Microalbuminuria every 6-12 months
    2. Initiating monitoring
      1. Type I Diabetes Mellitus: 5 years after diagnosis
      2. Type II Diabetes Mellitus: Start at time of diagnosis
  3. Labs: Urine Protein
    1. General
      1. Nephropathy diagnosis needs 2 of 3 samples positive
    2. Normal
      1. 24h Collection: <30 mg/day
      2. Timed Collection: <20 ug/min
      3. Spot Collection: <30 ug/mg Creatinine
    3. Microalbuminuria
      1. 24h Collection: 30-300 mg/day
      2. Timed Collection: 20-200 ug/min
      3. Spot Collection: 30-300 ug/mg Creatinine
    4. Clinical albuminuria
      1. 24h Collection: >300 mg/day
      2. Timed Collection: >200 ug/min
      3. Spot Collection: >300 ug/mg Creatinine
  4. Management
    1. Tight glycemic control
      1. Keep Hemoglobin A1C <7%
      2. Better glycemic control reduces nephropathy risk
      3. Microalbuminuria risk with Hemoglobin A1C > 8.1%
      4. Krolewski (1995) N Engl J Med 332(19):1251
    2. Control Hyperlipidemia
    3. Control Hypertension
      1. Antihypertensives
        1. ACE Inhibitors (preferred)
        2. Angiotensin Receptor Blockers (ARB)
          1. Also slows nephropathy progression
          2. Lewis (2001) N Engl J Med 345:851
        3. Non-Dihydropyridine Calcium Channel Blockers
          1. Example: Diltiazem
          2. Reduces Proteinuria (less than ACE Inhibitor)
        4. Avoid Dihydropyridine Calcium Channel Blockers
          1. Nifedipine, Amlodipine may increase Proteinuria
      2. Hypertension goals
        1. Keep Blood Pressure under 130/80
        2. Isolated Systolic Hypertension goals
          1. Keep Systolic Blood Pressure under 140
  5. Management: Dietary changes (incomplete evidence)
    1. Dietary modification: CR-LIPE
      1. Better than protein restriction in retarding CRI
      2. Components
        1. 50% carbohydrate restricted (CR)
        2. Low Iron available (LI)
        3. Polyphenol enriched (PE)
      3. References
        1. Facchini (2003) Diabetes 52:1204
    2. Protein restriction
      1. Near Normal GFR: <0.8g/kg/day Protein
      2. Falling GFR: <0.6g/kg/day Protein
  6. Referral to Nephrology Indications
    1. Serum Creatinine over 2.0 mg/dl
    2. Glomerular Filtration Rate (GFR) less than 70 ml/min
  7. Prognosis
    1. Dialysis usually needed when GFR reaches 10 ml/min
    2. GFR decline after onset microalbuminuria
      1. No ACE Inhibitor: 10 ml/min/year
      2. ACE Inhibitor: 4-6 ml/min/year
  8. References
    1. Molitch (1997) Am J Med 102:392
    2. Cooper (1998) Lancet 352:213
    3. Thorp (2005) Am Fam Physician 72:96

Diabetic Nephropathy (C0011881)

Definition (MSH)KIDNEY injuries associated with diabetes mellitus and affecting KIDNEY GLOMERULUS; ARTERIOLES; KIDNEY TUBULES; and the interstitium. Clinical signs include persistent PROTEINURIA, from microalbuminuria progressing to ALBUMINURIA of greater than 300 mg/24 h, leading to reduced GLOMERULAR FILTRATION RATE and END-STAGE RENAL DISEASE.
Definition (CSP)kidney disease and resultant kidney function impairment due to the long standing effects of diabetes on the microvasculature (glomerulus) of the kidney; features include increased urine protein and declining kidney function.
ConceptsDisease or Syndrome (T047)
ICD9250.4
MSHD003928
EnglishDiabetes + nephropathy, Diabetes with renal manifestations, Diabetes-nephrosis syndrome, Diabetic Kidney Disease, Diabetic Kidney Diseases, Diabetic Kidney Problems, Diabetic Nephropathies, Diabetic Nephropathy, Diabetic renal disease, Nephropathy - diabetic, Nephrotic syndrome in diabetes mellitus, Renal disorder associated with diabetes mellitus
Spanishdiabetes con manifestaciones renales, enfermedad renal diabetica, nefropatia diabetica, sindrome de diabetes - nefrosis, sindrome nefrotico en diabetes mellitus, trastorno renal asociado con diabetes mellitus
Parent ConceptsComplications of Diabetes Mellitus (C0342257), Diabetes Mellitus (C0011849), Kidney Diseases (C0022658), Diabetic Nephropathy (C0011881), Diabetic complications (C0271672), Renal disorders in systemic disease (C0403517), Ambiguous concept (C1274012)
SourcesCCS, COSTAR, CSP, ICD9CM, LCH, MEDLINEPLUS, MSH, MTH, NDFRT, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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