diabetic nephropathy

1. DIABETICDIABETIC
NEPHROPATHYNEPHROPATHY
Presented ByPresented By
Rashi TantiaRashi Tantia

2. INTRODUCTION and EPIDEMIOLOGYINTRODUCTION and EPIDEMIOLOGY
India has increased burden of chronic diseases like India has increased burden of chronic diseases like
Hypertension and DiabetesHypertension and Diabetes
India has largest number of diabetics in the world India has largest number of diabetics in the world
with prevalence of 3.8% in rural and 11.8% in urban with prevalence of 3.8% in rural and 11.8% in urban
adultsadults
25-40% of these develop End Stage Renal Disease 25-40% of these develop End Stage Renal Disease
which is now known as CKDwhich is now known as CKD
Both type 1 and type 2 diabetes lead to ESRD but Both type 1 and type 2 diabetes lead to ESRD but
majority of patients are those with NIDDMmajority of patients are those with NIDDM
In Diabetic Nephropathy, Glomeruli and Kidneys are In Diabetic Nephropathy, Glomeruli and Kidneys are
normal or increased in size unlike Polycystic kidney normal or increased in size unlike Polycystic kidney
disease where their size is reduced disease where their size is reduced

3. GOALS and OBJECTIVESGOALS and OBJECTIVES
To discuss the risk of development of To discuss the risk of development of
Diabetic nephropathyDiabetic nephropathy
To discuss the screening methods and To discuss the screening methods and
diagnosis of Diabetic nephropathydiagnosis of Diabetic nephropathy
To discuss the implications of To discuss the implications of
MicroalbuminuriaMicroalbuminuria
To discuss the management of To discuss the management of
nephropathy through Diet, Control of nephropathy through Diet, Control of
Blood Pressure, and Dialysis and Blood Pressure, and Dialysis and
Transplantation Transplantation

4. RISK FACTORSRISK FACTORS
Genetic FactorsGenetic Factors:- Person having family history :- Person having family history
of Diabetic nephropathy is more likely to of Diabetic nephropathy is more likely to
develop it as welldevelop it as well
Inadequate Glucose ControlInadequate Glucose Control:- Improved blood :- Improved blood
glucose level has found to reduce the risk of glucose level has found to reduce the risk of
nephropathynephropathy
High blood pressureHigh blood pressure:- Usually it occurs as a :- Usually it occurs as a
result of kidney disease but is also associated result of kidney disease but is also associated
with progression and pathogenesis of with progression and pathogenesis of
nephropathy nephropathy

5. Contd.Contd.
HyperlipidemiaHyperlipidemia
SmokingSmoking
Long Standing Diabetes:Long Standing Diabetes:- Patients having long - Patients having long
standing diabetes have higher risk of developing standing diabetes have higher risk of developing
nephropathynephropathy
PregnancyPregnancy:- During pregnancy, there is rise in :- During pregnancy, there is rise in
GFR which returns to normal after delivery. But GFR which returns to normal after delivery. But
hypertensive women or those with renal disease hypertensive women or those with renal disease
prior to conception have higher risk of prior to conception have higher risk of
progression of the disease progression of the disease

6. Natural History of Kidney Natural History of Kidney
DiseaseDisease
Diabetic Nephropathy progressesDiabetic Nephropathy progresses
through through five predictable stagesfive predictable stages which which
are as follows:-are as follows:-

7. Stage 1 (very early diabetes)
•Increased demand upon the kidneys is indicated by an
above-normal glomerular filtration rate (GFR).
•Hyperglycemia leads to increased kidney filtration
(see later)
•This is due to osmotic load and to toxic effects of
high sugar levels on kidney cells
•Increased Glomerular Filtration Rate (GFR >90ml/
min) with enlarged kidneys

8. Stage 2 (developing diabetes)
•Clinically silent phase with continued hyper filtration and
hypertrophy
•The GFR remains elevated or has returned to normal
(GFR 60-89ml/min), but glomerular damage has
progressed to significant microalbuminuria (small but
above-normal level of the protein albumin in the urine).
•Significant microalbuminuria will progress to end-stage
renal disease (ESRD).
•Therefore, all diabetes patients should be screened for
microalbuminuria on a routine basis.

9. Stage 3 (overt, or dipstick-positive diabetes)
•Glomerular damage has progressed to clinical albuminuria
with GFR 30-59ml/min.
•Basement membrane thickening due to AGEP
•The urine is "dipstick positive," containing more than 300
mg of albumin in a 24-hour period.
•Hypertension (high blood pressure) typically develops
during stage 3.

10. Stage 4 (late-stage diabetes)
•Glomerular damage continues, with increasing
amounts of protein albumin in the urine.
•The kidneys’ filtering ability has begun to
decline steadily, and blood urea nitrogen (BUN)
and creatinine (Cr) has begun to increase.
•The glomerular filtration rate (GFR) decreases
further more with (GFR 15-29ml/min). Almost
all patients have hypertension at stage 4.

11. Stage 5 (end-stage renal disease, ESRD or CKD,
chronic kidney disease)
•GFR has fallen to <15 ml/min and renal replacement
therapy (i.e., haemodialysis, peritoneal dialysis, kidney
transplantation) is needed.

12. KIDNEY FUNCTIONKIDNEY FUNCTION
Functional unit is NephronFunctional unit is Nephron
It filters the blood into the tubules which It filters the blood into the tubules which
have very thin wallshave very thin walls
Normally, materials that body needs flow Normally, materials that body needs flow
back and wastes are thrown back across back and wastes are thrown back across
these wallsthese walls
Most important is Glucose which is Most important is Glucose which is
reabsorbed back completely reabsorbed back completely

13. STRUCTURE OF A NEPHRONSTRUCTURE OF A NEPHRON

14. Normal v/s Declining Function of the KidneyNormal v/s Declining Function of the Kidney
Removal of nitrogenous waste Removal of nitrogenous waste
productsproducts
 Fluid and electrolyte and acid-Fluid and electrolyte and acid-
base balancebase balance
BP ControlBP Control
Excretion of certain drugsExcretion of certain drugs
Production of erythropoietinProduction of erythropoietin
Formation of 1,25-dehydroxy Formation of 1,25-dehydroxy
vitamin Dvitamin D
Increased serum BUN and Increased serum BUN and
creatininecreatinine
Fluid and sodium retention and Fluid and sodium retention and
increased serum potassium increased serum potassium
and metabolic acidosisand metabolic acidosis
HypertensionHypertension
Alteration of drug activityAlteration of drug activity
Decreased production of Decreased production of
Erythropoietin and hence Erythropoietin and hence
RBC’s and lead to anaemia and RBC’s and lead to anaemia and
HbA1C would always be low.HbA1C would always be low.
Decreased Calcium absorptionDecreased Calcium absorption

15. SCREENING METHODSSCREENING METHODS
It can be done by 3 methodsIt can be done by 3 methods:-:-
A random spot collection to ACRA random spot collection to ACR
A 24-hr collection for creatinineA 24-hr collection for creatinine
A timed (4-hr) collection A timed (4-hr) collection

16. Contd.Contd.
Annual check for proteinuria in fasting Annual check for proteinuria in fasting
urine sample using a urine dipstick:-urine sample using a urine dipstick:-
If it is +ve, person should check for If it is +ve, person should check for
urinary infection and a lab urine PCR urinary infection and a lab urine PCR
(Protein:Creatinine ratio)(Protein:Creatinine ratio)
If it is –ve, urine albumin should check If it is –ve, urine albumin should check
using a lab ACR (Albumin:Creatinine using a lab ACR (Albumin:Creatinine
ratio) ratio)

17. Contd.Contd.
If PCR or ACR are elevated check should be If PCR or ACR are elevated check should be
repeated twice in next 4 months.repeated twice in next 4 months.
ACR ACR <2.5mg/mmol<2.5mg/mmol is normal in males is normal in males
ACR ACR <3.5mg/mmol<3.5mg/mmol is normal in is normal in
females females

18. ADA and CDA Recommended Urine ADA and CDA Recommended Urine
LevelsLevels
Urine Urine
dipstick dipstick
for proteinfor protein
Urine ACRUrine ACR
mg/mmolmg/mmol
24-hr24-hr urine urine
collection collection
for for
albuminalbumin
NormalNormal NegativeNegative
<2.0(men)<2.0(men)
<2.8(women)<2.8(women)
<30mg/day<30mg/day
MicroalbumiMicroalbumi
nurianuria
NegativeNegative
20-20.0(men)20-20.0(men)
2.8-28(women)2.8-28(women)
30-300mg/day30-300mg/day
Overt Overt
nephropathynephropathy
NegativeNegative>>20(men)20(men)
>28(women)>28(women)
>300mg/day>300mg/day

19. MANAGEMENTMANAGEMENT
Presence of Presence of Microalbuminuria Microalbuminuria indicates that treatment indicates that treatment
should be started:-should be started:-
Use of ACE Inhibitor is essential as microalbuminuria Use of ACE Inhibitor is essential as microalbuminuria
indicates increased pressure in kidney.indicates increased pressure in kidney.
BP should be managed to achieve <130/80mmHg.BP should be managed to achieve <130/80mmHg.
HbA1c should be managed to <6.5%.HbA1c should be managed to <6.5%.
Reduce protein in diet to 0.8-1.0gm/Kg body weight in Reduce protein in diet to 0.8-1.0gm/Kg body weight in
early stages and to <0.8gm in later stages of CKD.early stages and to <0.8gm in later stages of CKD.
Lipid management, non-smoking, aspirin therapy is also Lipid management, non-smoking, aspirin therapy is also
helpful.helpful.
When GFR falls <60ml/min/1.73mt.sq. BSA, person When GFR falls <60ml/min/1.73mt.sq. BSA, person
should be referred to a Nephrologist.should be referred to a Nephrologist.

20. PREVENTION OR DELAYPREVENTION OR DELAY
Achieving blood glucose level in normal range Achieving blood glucose level in normal range
can either delay the start or progression of can either delay the start or progression of
MicroalbuminuriaMicroalbuminuria to to Macroalbuminuria. Macroalbuminuria.
(DCCT&UKPDS)(DCCT&UKPDS)
Lowering BP reduces the development of Lowering BP reduces the development of
kidney disease. (UKPDS-1998)kidney disease. (UKPDS-1998)
According to (DCCT-1993), intensively According to (DCCT-1993), intensively
managed group had managed group had 40% decrease40% decrease in the in the
occurrence of occurrence of Microalbuminuria Microalbuminuria and and 50% 50%
decreasedecrease in the occurrence of in the occurrence of
Macroalbuminuria.Macroalbuminuria.

21. SYMPTOMSSYMPTOMS
No symptoms of early kidney disease.No symptoms of early kidney disease.
If one waited for symptoms to appear, If one waited for symptoms to appear,
person would have significant disease person would have significant disease
on diagnosis. on diagnosis.
Solution at this stage is either Solution at this stage is either DialysisDialysis
or or Kidney Transplantation. Kidney Transplantation.

22. DIALYSISDIALYSIS
It is a method where blood is cleaned off It is a method where blood is cleaned off
wastes artificially when kidneys are not wastes artificially when kidneys are not
able to do it properly.able to do it properly.
There are two types of Dialysis:-There are two types of Dialysis:-
HemodialysisHemodialysis
Peritoneal Dialysis Peritoneal Dialysis

23. HEMODIALYSISHEMODIALYSIS

24. Contd.Contd.
As you can see, it uses a machine to take As you can see, it uses a machine to take
over the function of the kidney.over the function of the kidney.
It requires a surgical procedure to create a It requires a surgical procedure to create a
shunt between arteries and veins known shunt between arteries and veins known
as as AV FistulaAV Fistula. .

25. PERITONEAL DIALYSISPERITONEAL DIALYSIS

26. Contd.Contd.
As you can see, in this, a solution is run As you can see, in this, a solution is run
into the abdominal cavity, left for few into the abdominal cavity, left for few
hours and drained off, taking with it hours and drained off, taking with it
wastes from the blood.wastes from the blood.
People can do this at homes during People can do this at homes during
sleeping hours. sleeping hours.

27. KIDNEY TRANSPLANTATIONKIDNEY TRANSPLANTATION
Also known as Renal TransplantAlso known as Renal Transplant
Quite common now a days mostly in Quite common now a days mostly in
young patientsyoung patients
Good success rates if kidney is received Good success rates if kidney is received
from a living relativefrom a living relative

28. To Wrap UpTo Wrap Up:- :-
Diabetic nephropathy is a disease that develops Diabetic nephropathy is a disease that develops
slowly and if treated early, progression can be slowly and if treated early, progression can be
delayed.delayed.
There are no signs and symptoms of early There are no signs and symptoms of early
disease so screening is important.disease so screening is important.
Aggressive treatment of Blood glucose, BP, Aggressive treatment of Blood glucose, BP,
Lipids helps in prevention of renal function and Lipids helps in prevention of renal function and
can improve the outcome.can improve the outcome.
In CKD, some people progress to Dialysis and In CKD, some people progress to Dialysis and
few to Kidney Transplantation. few to Kidney Transplantation.

29. THANK YOUTHANK YOU

30. BIBLIOGRAPHYBIBLIOGRAPHY
1. Diabetes Education Module, 20061. Diabetes Education Module, 2006
2. ADA, 2007;CDA,20032. ADA, 2007;CDA,2003
3. IDF,2005;ADA,20073. IDF,2005;ADA,2007
4. Malhotra, 19994. Malhotra, 1999
5. UKPDS,1998 and DCCT,1993 5. UKPDS,1998 and DCCT,1993
6.6.http://www.slideworld.org/slideshow.aspx/diabetic http://www.slideworld.org/slideshow.aspx/diabetic
nephropathy pptnephropathy ppt
7.The Everything Diabetes Book, Ford Martin with 7.The Everything Diabetes Book, Ford Martin with
Blumer, M.D. Blumer, M.D.