Diabetic Nephropathy

Question 1

What is the difference between diabetic nephropathy and diabetic glomerulopathy?

Answer 1

Diabetic glomerulopathy has biopsy proven changes

Diabetic nephropathy is kidney disease thought to be due to diabetes

Question 2

Describe the pathological changes in diabetic nephropathy

Answer 2

Glycosylation of GBM proteins causes mesangial expansion (which forms Kimmelsteil-Wilson) nodules and disrupts filtration slits between podocytes

There is also hyaline arteriosclerosis which initially when affecting the efferent arteriole causes hyperfiltration but later causes glomerulosclerosis

Question 3

How often should diabetic patients be screened for the development of diabetic nephropathy?

Answer 3

At least every year- they should be screened for all micro-vascular complications:
Retinal photographs- for retinopathy
Foot checks- nephropathy (and microangiopathy)
Nephropathy- Annual EGFR and ACR, Urine dip for proteinuria (can be done in primary care)

Question 4

What blood pressure should be targeted in diabetic patients with CKD?

Answer 4

130/80

Question 5

What are the risk factors for developing diabetic nephropathy?

Divide answer into modifiable and non-modifiable

Answer 5

Poor glycemic control
Longer duration of diabetes (earlier diagnosis in Type 1)
Smoking
Hypertension
Increasing age
Presence of other micro-vascular complications
Gender
Ethnicity
RAAS blockage (prevents auto-regulation at the glomerulus)
Chronic NSAID use

Question 6

If a diabetic patient tests positive for proteins in the urine, what features would make you consider other diagnoses instead of diabetic nephropathy?

Answer 6

Haematuria on dipstick
Rapid decline in eGFR (diabetic nephropathy occurs slowly over many years)
No other micro-vascular complications
Short duration of having had diabetes
Systemic features such as rash, recurrent nose bleeds

Question 7

What tests should be done to screen diabetic patients for nephropathy?

Answer 7

eGFR
Urine ACR
Urine dip for proteins

Question 8

If someone tests positive for albuminuria, what should be done?

Answer 8

Another urine sample 2-6 months later

Advice mid-stream first void urine and not to eat meat before it is taken

Question 9

What is the management for diabetic nephropathy?

Answer 9

Improve glycemic control 
Manage HTN (ACEi, ARBs)
Stop smoking
Diet and lifestyle changes for better glycemic control
Reduce salt intake