Diabetic nephropathy
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Diabetic nephropathy. Diabetic nephropathy- definition. Chronic microangiopathy type complication of DM characterized by: proteinuria hypertension p rogressive loss of GFR leading to ESRD. Microalbuminuria. albumin excretion in urine 30 – 300 mg/d or 20 – 200 ug/min

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Diabetic nephropathy definition

Diabetic nephropathy- definition

Chronic microangiopathy type complication of DM characterized by:

proteinuria

hypertension

progressive loss of GFR leading to ESRD


Microalbuminuria
Microalbuminuria

  • albumin excretion in urine

    30 – 300 mg/d or 20 – 200 ug/min

    2. If temporary, but >80 mg/d it means in 95% progression to continuous microalbuminuria

    3. If continuous - it means threatening nephropathy. Not treated increases 20 – 40% a year. After 5 years becomes macroalbuminuria= evident diabetic nephropathy


Macroalbuminuria
Macroalbuminuria

  • Albumin excretion in urine >300 mg/d

    2. It may lead to development of nephrotic syndrome (proteinuria, hypoalbuminaemia, hyperlipidaemia, edema)

    3. ESRD appears usually after 5 years


Tim e course of dn according to type of dm mogensen scale
Time course of DN according to type of DM (Mogensen scale)

IDDM NIDDM

I stadium (0-2 yrs) hyperfiltration (100%) (unnoticeable)

II stadium (2-5yrs) silent DN (100%) (100%)

III stadium (>5 yrs) threatening DN (30%) (30%)

IV stadium (>15 yrs) evident DN (25%) (25%)

V stadium (>15 yrs) ESRD (20%) (20%)


Factors contributing to development of dn
Factors contributing to development of DN

  • Long-lasting hyperglycemia

  • Family predisposition

  • HT

  • High-protein diet

  • Cigarette smoking

  • hyperlipidaemia


Bp in children of dm patients
BP in children of DM patients

without DN with DN

SBP 117 +13 mmHg 125 +17 mmHg

Strojek i wsp.

Mutual coincidence of DM and HT


DM patients with HT

  • Age of DM patients = % of patients with HT



Treatment of dn
Treatment of DN

  • Proper treatment of DM

  • Proper treatment of HT

  • Quit smoking habit

  • Control of protein content in diet

  • Early treatment of anaemia

  • Early kidney replacement therapy


Proper treatment of dm
Proper treatment of DM

  • „Almost normal” glycaemia:

    fasting 60 – 140 mg/dl

    2 h after meal <200 mg/dl

  • Proper body mass

  • Correction of hyperlipidaemia


Proper treatment of bp
Proper treatment of BP

  • Lowest tolerable BP

  • Treatement with ACE-I & AT-II


Nutrition state (albuminaemia) and the risk of death

Hakim 1994


Early treatment of anaemia with epo
Early treatment of anaemia with epo

Anaemia… when?

glomerulonephritis DN

GFR <25-30 ml/min<35-40 ml/min

creatinine >3-4 mg/dl >2-3 mg/dl

Attention:

ACE-I may contribute to anaemia!


Early start of renal replacement therapy
Early start of renal replacement therapy

  • creatinine >3,5 – 4 mg/dl – a-v fistula!

  • creatinine >4,5 – 5 mg/dl (GFR <20 ml/min): - consider KTx

    (<45 yrs & IDDM)

    - consider KTx and pancreas Tx

    (>45 yrs & NIDDM)

    - start RRT


Hd therapy in dm patients

HD therapy in DM patients

Pro: Contra:

High efficiacy CVS damage

Frequent control problems with a-v fistula

No protein loss Hypotonia

frequent hypoglycaemia

frequent hyperkalaemia


Cado treatment in dm patients

CADO treatment in DM patients

Pro: Contra:

CVS neutral risk of infection

No a-v protein loss

Good control of kalaemia hernias

Good control of glycaemia helper required


Glycaemia regulation in dm patients with esrd
Glycaemia regulation in DM patients with ESRD

  • Gluconeogenesis decreased by 30 – 40%

  • Insulin requirement decreased 3-4x

    3.Decreased metabolism of some oral drugs (eg. metformin)

  • During HD glucose is „hemodialysed” and lost

    All the above may lead to hypoglycaemia!


Dm patient on hd therapy what should be the treatment
DM patient on HD therapy- what should be the treatment?

  • Insulin – 2-3x lower doses!

  • Oral drugs – short acting, metabolized in liver eg:

    - glipizyd (Glipizyd, Minidiab, Glibenese GITS)

    - gliclazyd (Diaprel, Diabezyd)

    - glikwidon (Glurenorm)


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