Diabetic Nephropathy


Article Author:
Ron Varghese


Article Editor:
Ishwarlal Jialal


Editors In Chief:
James Beauchamp
Mark Pellegrini
Nicole Hale-Crutch


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
11/15/2018 9:34:46 PM

Introduction

Diabetic kidney disease (DKD) is the main cause of end-stage kidney disease (ESKD), in the developed countries including the United States.[1] It is considered a microvascular complication and occurs in both diabetes mellitus type 1 (T1DM) and diabetes mellitus type 2 (T2DM). Reliable tests for diagnosis and monitoring include urine albuminuria and the estimated GFR (eGFR). Optimizing glycemia and good blood pressure control are pivotal in halting the progression of DKD.[2]

Etiology

Thirty percent to 40% of patients with diabetes mellitus (DM)develop diabetic nephropathy.[3]

Epidemiology

While patients with type 2 diabetes mellitus may present with albuminuria at the time the diabetes is detected, diabetic nephropathy develops in type 1 diabetes 15 to 20 years later. This difference is mainly because the precise onset of type 2 diabetes is difficult to discern. Structural and functional changes occur in the kidney on account of diabetes and result in proteinuria, hypertension, and progressive reduction of kidney function, which is the hallmark of diabetic nephropathy.

Certain racial groups like African Americans, Native Americans, and Mexican Americans are at high risk of developing diabetic nephropathy. Studies have noted familial clustering, hinting that genetics plays a part in the risk of developing nephropathy.

Pathophysiology

Hyperglycemia leads to the production of reactive oxygen species and activation of pathways including protein kinase C, polyol, hexosamine, and advanced glycation end products (AGE). A significant feature is marked inflammation manifested by an increase in cytokines and chemokines including IL-6, MCP-1, TGF-beta (transforming growth factor- beta) and VEGF (vascular endothelial growth factor), causing inflammation fibrosis and increased vascular permeability. A podocytopathy ensues resulting in albuminuria. The resulting systemic and intraglomerular hypertension results in proteinuria. Proteinuria causes epithelial-mesenchymal cell transformation leading to fibroblasts and chronic tubular injury.

Histopathology

Kimmelstiel-Wilson nodules, glomerular basement membrane thickening, and glomerular sclerosis, inflammation are the common pathologies seen in diabetic nephropathy.

History and Physical

Increasing duration of DM, poor glycemic control, and uncontrolled hypertension are strong risk factors for the development of diabetic nephropathy (DN). A family history of hypertension and cardiovascular events in first-degree relatives is also a strong risk factor for developing diabetic nephropathy. Obesity, smoking, and hyperlipidemia are risk factors for DN. This, along with family clustering, suggests genetic factors could also be at play. Several genes including polymorphisms in angiotensin converting enzyme (ACE) and angiotensin receptor are being studied. Males are at higher risk for developing diabetic nephropathy.

Diabetic nephropathy is diagnosed by persistent albuminuria on 2 or more occasions, separated at least by 3 months on early morning urine samples. Persistent albuminuria is greater than 300 mg over 24 hours or greater than 200 micrograms per minute. Moderately increased albuminuria is when the urine albumin excretion rate is between 30 to 300 mg over 24 hours and is a marker of early DN. It is critical to exclude a urinary tract infection as the cause of the albuminuria by a urinalysis. 

Early in the course of the disease, patients are often asymptomatic and are diagnosed during screening with levels of 30 to 300 mg/G creatinine. Once nephropathy sets in, patients present with fatigue, foamy urine (urine protein greater than 3.5 g per day), and pedal edema due to hypoalbuminemia and nephrotic syndrome. They may also have associated peripheral vascular disease, hypertension, coronary artery disease, and diabetic retinopathy.

Evaluation

Proteinuria is the hallmark of diabetic nephropathy. The absence of retinopathy makes diabetic nephropathy less likely in T1DM.

The scenario is more difficult in T2DM than with T1DM. The exact time of onset of T2DM is unclear in most patients. History and physical exam play a crucial role in diagnosing diabetic nephropathy in T2DM.

Treatment / Management

Treatment of diabetic nephropathy targets 4 areas: cardiovascular risk reduction, glycemic control, control of blood pressure, and inhibition of the renin-angiotensin system (RAS).

Risk-factor modification, including tobacco cessation and optimal lipid control strategies, are crucial for cardiovascular risk reduction.

Studies have shown a significant reduction in risk of developing proteinuria and microalbuminuria with intensive diabetes control in T1DM.[4] These studies include DCCT (Diabetes Control and Complications Trial) and EDIC (Epidemiology of Diabetes Interventions and Complications study). The benefits of good glycemic control early in the onset of disease carried over even after a long time, despite glycemic control being similar in both groups on longer follow up. This effect is "metabolic memory," a term coined by DCCT/EDIC investigators.

In T2DM, UKPDS (United Kingdom Prospective Diabetes Study) showed that targeting a HbA1C of 7% led to lower risk of microvascular complications including nephropathy.[5] However, blood pressure (BP) control also led to a decrease in cardiovascular mortality.

Studies have shown the benefit of ARBs (angiotensin receptor blockers) in delaying the progression of kidney disease.[6][7] These include studies like RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan Study) and IDNT (Irbesartan Diabetes Nephropathy Trial), which also showed that the BP achieved, better-predicted kidney outcome rather than BP at entry, emphasizing the need for BP control. UKPDS showed the benefit of BP control on any DM-related complication such as death, adverse cardiovascular events, and the composite of microvascular events. However aggressive control of systolic BP to less than 120 mm Hg, as opposed to standard therapy (less than 140 mm Hg systolic), found no difference in cardiovascular outcome or end-stage renal disease. The Eighth Joint National Committee (JNC 8) guidelines recommend a goal BP less than 140/90 mm Hg for most patients with T2DM and diabetic nephropathy, but with individualization.[8] Recent diabetic society guidelines suggest goals of 130/80 for people with diabetes.

While RAS blockade is crucial to prevent the development of diabetic nephropathy, multiple studies show that early therapy in patients with T1DM is ineffective in preventing the development of microalbuminuria. However, studies including ROADMAP (Randomized Olmesartan and Diabetes Microalbuminuria Prevention) have shown that RAS blockade can prevent development of microalbuminuria in T2DM.[9]

Studies like IRMA2 (Irbesartan in Microalbuminuria, Type 2 Diabetic Nephropathy Trial) have shown the benefit of ARB in preventing proteinuria in patients with microalbuminuria.[10] Studies in patients with T1DM and overt proteinuria have also shown that ACE inhibitors slow the progress of diabetic nephropathy. The IDNT and RENAAL studies have shown similar benefit in T2DM patients. These studies provide clear evidence of the benefit of RAS-blocking medication on slowing progression of diabetic nephropathy, independent of their effect on BP. However, the use of more than one RAS-blocking agents resulted in multiple adverse outcomes including acute renal failure and has fallen out of favor.

Newer drugs like a third-generation mineralocorticoid receptor antagonist, finerenone, has shown albuminuria reduction in diabetic nephropathy at 90 days, on patients already on ARB.[11] The EMPAREG and CANVAS studies showed that SGLT2 (sodium glucose co-transporter 2) inhibitors that prevent reabsorption of glucose via the renal tubules reduced cardiovascular mortality.[12] In these cardiovascular outcome trials, the SGLT2 inhibitors had positive effects on kidney outcomes, namely albuminuria reduction and a reduction in the occurrence of a composite renal outcome. However, since these are secondary outcomes of trials designed to test cardiovascular benefit, many studies are now underway to test the actual potential of this group of drugs to prevent progression of diabetic nephropathy.

Toxicity and Side Effect Management

Effect of CKD on Diabetes Drugs

The kidneys play a crucial role in clearing insulin from the body.  When the kidney fails, insulin remains for longer periods in the body, and this warrants dose reduction of insulin to prevent hypoglycemia. This principle also is true for most oral antidiabetic medications that are cleared from the kidney.

Metformin is contraindicated in patients with eGFR less than 30 mL/min/1.73 m2, due to the likelihood of lactic acidosis. With most oral drugs the physician needs to be cautious when the eGFR is less than 45 mL per minute and especially below 30 mL per minute.

Patients with diabetic nephropathy are at risk of developing acute kidney injury (AKI) and, one must exercise extreme caution with the use of nephrotoxic medications like NSAID, intravenous contrast, among others.

Consultations

When the eGFR is below 45 mL per minute, and the patient has albuminuria greater than 300 mg/G creatinine a nephrology consult is prudent to establish a baseline for future renal replacement therapy.

Deterrence and Patient Education

Protein intake should be around 0.8 g per kilogram body weight.

Enhancing Healthcare Team Outcomes

Interdisciplinary clinical teams have been crucial in reducing cardiovascular risk factors, glycemic control and decreased risk of complications, across multiple countries [13]. The current recommendation is that the patient also is included as a member of this interprofessional treatment team for optimal outcomes. The nurse should educate the patient on the importance of glucose control and a healthy diet, whereas the pharmacist should educate the patient on medication compliance. Further, these patients should be taught how to monitor and treat their blood glucose levels at home. Studies show that patients who remain compliant with home monitoring of blood glucose tend to have a delay in renal dysfunction.[14]


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Diabetic Nephropathy - Questions

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Which of the following antihypertensive medications would be most appropriate for a patient with a history of diabetes mellitus and hypertension who is found to have microalbuminuria?



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What is the most common cause of end-stage renal disease in North America?



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A 55-year-old is told that he has Kimmelstiel Wilson syndrome. This signifies the presence which of the following conditions?



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A 68-year-old African American male with poorly-controlled diabetes mellitus presents with new onset of bilateral swelling in his feet. He is insulin dependent and takes an ACE inhibitor. On exam, there is three-plus pitting edema of his lower extremities bilaterally. Blood work reveals a creatinine of 2.6 mg/dL and potassium 6 mg/dL. Past medical records indicate that his creatinine has been the same over the last 2 years. The ECG is normal. What is the most appropriate next step in management?



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Which class of medications often have been shown to reduce diabetic nephropathy?



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A patient with type 2 diabetes mellitus is at a high risk for which of the following kidney disorders?



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Which of the following drugs is found to prevent progression of renal damage in patients with diabetes mellitus?



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A 65-year-old patient with a 22-year history of diabetes mellitus type 2 and well-controlled hyperlipidemia presents with new-onset hypertension. Her hemoglobin A1C is 6.8. What is the best initial medication to treat her hypertension?



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Which of the following medications can reduce disease progression in patients with diabetic nephropathy?



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What is the most sensitive test for screening for diabetic nephropathy?



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A 50-year-old obese female has had monilial vaginitis persisting over 6 months despite trials of over-the-counter topical products and oral fluconazole. Laboratories confirm elevation of BUN, creatinine, and glucose. Urinalysis shows glucose and 1+ protein. What would be the appearance of the glomeruli on renal biopsy?



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What is the first sign of diabetic nephropathy?



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What is an early sign of diabetic nephropathy?



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What is the appropriate treatment of diabetic nephropathy?



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A 65-year-old female patient comes in with complaint of swelling of her ankles and feet. She noticed an increase need to urinate for the past three weeks. She has a history of hypertension and type 2 diabetes mellitus treated with metoprolol and metformin. On examination, her blood pressure is 160/100 mmHg and heart rate 65 bpm. Cardiovascular examination is normal with breath sounds equal on both the sides. On physical examination, bilateral swelling is noted on her feet and ankles. A dipstick urine test was done in the office and was positive for 2+ protein. What medication would most likely benefit this patient?



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Which of the following is not a risk factor for the progression of diabetic nephropathy?



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What percentage of patients with type 1 diabetes mellitus develop microalbuminuria 7 years after diagnosis?



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Which of the following medications has been shown to reduce albuminuria in patients with diabetic nephropathy when added to an ACE inhibitor?



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Which of the following medications is contraindicated in patients with an estimated glomerular filtration rate (eGFR) less than 30 ml/min/1.73 m2 due to an increased risk of lactic acidosis?



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Which of the following medications is safe for pain control in patients with diabetic nephropathy?



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The benefits of intensive glycemic control early in diabetes mellitus to prevent microvascular and macrovascular complications remain after several years. What is this phenomenon called?



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A 68-year-old woman with a long-standing history of diabetes mellitus and hypercholesteremia presents for follow up. Her current medications include insulin and atorvastatin. She has completed ambulatory blood pressure monitoring one day ago which found an average blood pressure of 152/98mmHg. The examination is unremarkable. Her urine exam reveals moderately increased albuminuria in the absence of pyuria. You plan to add another medication to her treatment. Which of the following is the most appropriate information regarding this medication that you should share with this patient?



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Diabetic Nephropathy - References

References

Rabkin R, Diabetic nephropathy. Clinical cornerstone. 2003     [PubMed]
Umanath K,Lewis JB, Update on Diabetic Nephropathy: Core Curriculum 2018. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2018 Jun     [PubMed]
Effect of intensive diabetes treatment on albuminuria in type 1 diabetes: long-term follow-up of the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications study. The lancet. Diabetes     [PubMed]
Genuth S,Eastman R,Kahn R,Klein R,Lachin J,Lebovitz H,Nathan D,Vinicor F, Implications of the United kingdom prospective diabetes study. Diabetes care. 2003 Jan     [PubMed]
Brenner BM,Cooper ME,de Zeeuw D,Keane WF,Mitch WE,Parving HH,Remuzzi G,Snapinn SM,Zhang Z,Shahinfar S, Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. The New England journal of medicine. 2001 Sep 20     [PubMed]
Lewis EJ,Hunsicker LG,Clarke WR,Berl T,Pohl MA,Lewis JB,Ritz E,Atkins RC,Rohde R,Raz I, Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. The New England journal of medicine. 2001 Sep 20     [PubMed]
Armstrong C, JNC8 guidelines for the management of hypertension in adults. American family physician. 2014 Oct 1     [PubMed]
Menne J,Ritz E,Ruilope LM,Chatzikyrkou C,Viberti G,Haller H, The Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) observational follow-up study: benefits of RAS blockade with olmesartan treatment are sustained after study discontinuation. Journal of the American Heart Association. 2014     [PubMed]
Parving HH,Lehnert H,Bröchner-Mortensen J,Gomis R,Andersen S,Arner P, The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. The New England journal of medicine. 2001 Sep 20     [PubMed]
Bakris GL,Agarwal R,Chan JC,Cooper ME,Gansevoort RT,Haller H,Remuzzi G,Rossing P,Schmieder RE,Nowack C,Kolkhof P,Joseph A,Pieper A,Kimmeskamp-Kirschbaum N,Ruilope LM, Effect of Finerenone on Albuminuria in Patients With Diabetic Nephropathy: A Randomized Clinical Trial. JAMA. 2015 Sep 1     [PubMed]
Rastogi A,Bhansali A, SGLT2 Inhibitors Through the Windows of EMPA-REG and CANVAS Trials: A Review. Diabetes therapy : research, treatment and education of diabetes and related disorders. 2017 Dec     [PubMed]
McGill M,Blonde L,Chan JCN,Khunti K,Lavalle FJ,Bailey CJ, The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios. Journal of clinical     [PubMed]
McFarlane P,Cherney D,Gilbert RE,Senior P, Chronic Kidney Disease in Diabetes. Canadian journal of diabetes. 2018 Apr     [PubMed]
Mahnensmith RL,Zorzanello M,Hsu YH,Williams ME, A quality improvement model for optimizing care of the diabetic end-stage renal disease patient. Seminars in dialysis. 2010 Mar-Apr     [PubMed]
Shen ZZ,Huang YY,Hsieh CJ, Early short-term intensive multidisciplinary diabetes care: A ten-year follow-up of outcomes. Diabetes research and clinical practice. 2017 Aug;     [PubMed]

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