Diabetic Nephropathy. Dr Peter Andrews Consultant Nephrologist St Helier Hospital, Carshalton, Surrey Frimley Park Hospital, Surrey Farnham HD Unit. Topics to be Covered. Demographics of diabetic renal disease Screening and diagnosis How can diabetic nephropathy be reduced? BP control
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Dr Peter Andrews
St Helier Hospital, Carshalton, Surrey
Frimley Park Hospital, Surrey
Farnham HD Unit
New Patients/Million Population
Year of ESRD Incidence
Rate per Million Pop./Year
Diabetes * 23%
Renovascular disease * 21%
Chronic interstitial disease 10%
Obstructive uropathy * 8%
Cystic disease 3%
Miscellaneous (amyloid, myeloma) 5%
Clinical type 2 diabetes
Rising blood pressure
Rising serum creatinine levels
End-stage renal disease
Onset of diabetes
*Kidney size , short-term GFR , long-term GFR .
†GBM thickening , mesangial expansion ,hypertensive changes +/-.
Early morning specimen
PREVEND - increase in cardiovascular mortality of x1.35 for each doubling of urinary albumin excretion
In the elderly, women and malnourished >50% of the GFR will be lost before the creatinine rises above the normal hospital range
Alternative is to measure creatinine clearance
which gives a more accurate measurement in mild
renal impairment, BUT
A better alternative is to use a formula to predict GFR
from plasma creatinine measurement eg Cockcroft-Gault:
Cr Cl ml/min = 1.23 x (140-age) x weight in kg
plasma creatinine umol/l
HOPE study : Patients at high risk of cardiovascular events. Mann JF Ann Intern Med 2001 134:629-36
Indications: Atypical clinical course
Absence of retinopathy
High grade proteinuria
Reasons: Exclude other pathology
“The UKPDS has shown that intensive blood glucose control reduces the risk of diabetic complications, the greatest effect being on microvascular complications”
Glucose Control Study Summary Disease
Aggregate Clinical Endpoints Disease
risk reduction Disease37% p=0.0092Effect of BP on Microvascular endpoints - incl ESRFTight control (< 150/85) or less tight control (< 180/105)
0Type II Diabetes and Hypertension:
Cardiovascular mortality rate/10,000 person-yr
Systolic blood pressure (mm Hg)
Stamler J et al. Diabetes Care. 1993;16:434-444.
Major cardiovascular events/1,000 patient-years
p=0.005 for trend
Target Diastolic Blood Pressure
Hansson L et al. Lancet. 1998;351:1755-1762.
Mean arterial pressure (mm Hg)
r = 0.66; p<0.05
Results of studies ³ 3 years in patients with type 2 diabetic nephropathy.
Bakris GL. Diabetes Res Clin Pract. 1998;39(suppl):S35-42.
-0.60Are all agents equal in terms of renoprotection?
Log change from baseline
Calcium channel blockers
Meta-regression analysis of 100 studies totaling 2494 patients with type 1 and type 2 diabetes.
*p<0.05 vs calcium channel blockers.
†p<0.05 vs control.
Kasiske BL et al. Ann Intern Med. 1993;118:129-138.
Capillary loops and mesangial cells
Lancet Sept 2003
Care re K+
? Spironolactone better alternative