-
International Journal of Diabetes and Endocrinology
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals
Re
sear
ch A
rtic
le
Sumon Rahman Chowdhury*1, Tasnuva Tanzil2, Rezaul Haider
Chowdhury3, Alam Mohammad Sharif 4
1Senior Medical Officer, Department of Diabetes, Endocrinology
and Metabolism, Chittagong Diabetic General Hospital, Chittagong
2Assistant Registrar, Department of Anaesthesia and Intensive Care
Unit, Chattogram Medical College Hospital 3Consultant Internist,
Department of Internal Medicine, Chittagong Diabetic General
Hospital 4Consultant, Department of Physical Medicine, Chittagong
Diabetic General Hospital
Corresponding author: Sumon Rahman Chowdhury, Senior Medical
Officer, Department of Diabetes, Endocrinology and Metabolism,
Chittagong Diabetic General Hospital, Chittagong. Tel: 01670393031;
E-mail: [email protected]
Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
10.46715/ijde2020.11.1000108
Received Date: 12 November, 2020; Accepted Date: 16 November,
2020; Published Date: 23 November, 2020
Keywords: Diabetic Nephropathy, Diabetes, Health Care
Professionals
Introduction
Diabetic Nephropathy (DN) is the leading cause of ESRD in the
UK. In 2012, DN accounted for 26% of cases ESRD [1], and 40%
diabetics will develop DN [2].
The features of DN are increasing urinary albumin excretion,
rising BP and declining renal function [3]. There are specific
pathological changes with five different stages. The key is the
level of urinary albumin excretion-microalbuminuria (incipient
nephropathy) or macroalbuminuria/proteinuria (overt nephropathy)
[4]. As it is an asymptomatic process screening is required [2,
3].
Normal Microalbuminuria Macroalbuminuria
ACR- Albumin/Creatinine
Ratio (mg/mmol)
-
Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
10.46715/ijde2020.11.1000108
In T1DM microalbuminuria usually appears after 5-15 years post
diagnosis, with proteinuria/ macroalbuminuria found in 15-40% [2,
5]. Not all will have increasing UAE in T1DM a third will revert to
normal [7].
Risk factors include duration of DM, hyperglycaemia,
hypertension, ethnicity and genetic factors. The UKPDS and DCCT
showed that improved glycaemia reduced progression
[4, 8, 9], and in T2DM, controlling hypertension reduces
risk
[4]. Suppression of RAS is the key to risk reduction [2, 3,
10].
There is increased cardiovascular risk [2, 3]. Compared to
normal UAE, microalbuminuria increases CVD risk by 2-3 times. With
proteinuria this risk is increased by 103.
Diabetic nephropathy can be easily screened for and the
modification of risk factors can improve the outcome. We will
discuss the risk factors, pathogenesis, staging and treatment of
this important cause of mortality and morbidity.
Search Strategy
Available studies and abstracts were identified through Pub Med
and Medline data bases (From 1998-2019) and Cochrane data bases.
Key search terms were diabetes and nephropathy. All available
studies and abstracts describing the relationship between diabetes
and nephropathy were included. The reference list of review
articles was also searched.
Discussion
Epidemiology
Approximately 463 million people worldwide have diabetes and the
prevalence is expected to rise to 700 million in the next 20 years
[11]. This growing epidemic carries with it an increasing burden of
micro and macrovascular complications. Diabetic nephropathy is one
of the serious microvascular complications of diabetes [12].
Diabetic nephropathy is defined as eGFR of 30 mg/g. It occurs in
up to 40% of all patients with diabetes [13] and accounts for
>44% of ESRD patients [14]. The prevalence of DN has doubled
over the past decade, especially in areas of high prevalence of
diabetes like USA, Japan and Europe. About 50% of DN patients will
progress to ESRD within 10 years of diagnosis, increasing to 75% in
20 years if no preventive measures are implemented [13].
Diabetic nephropathy contributes significantly to the economic
burden of diabetes. In UK, the cost of diabetic complications
in
2011/2012 was estimated at £14 billion, by 2035/2036 this is
expected to rise to £22 billion. Worldwide, healthcare costs for
diabetic patients are much higher than non- diabetic patients.
Also, among diabetic patients the cost of health care is much
higher in those with complications (Micro < Macro
-
Figure 6: Postsurgical photograpgh showing wide excision of
mass located in retromolar área.
Discussion
These type of tumours are very rare they comprise only 5% of
neoplasms and are seen in 0.4-2.6 for every 100,000 cases
around
the world, the mucoepidermoid tumour affects parotid and
minor
salivary glans in adults and is mostly seen in women and
Young
adults, most tof the cases arise in the the parotid gland with
this
ccase accounting for only 2-4% of the cases because it was seen
in
the submandibular gland, this patient is currently under
treatment
he was performed two sugeries for removal of ganglions
locanated
in neck and in the submandbullary gland, highes prevalence for
this
type of tumour is around the fifth decade of life and they can
be
asymptomatic like in this case with the patient having few to
no
symptoms. It has a puripotent cell origin and as we mention
can
be classidief into three stages [3].
References
Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
10.46715/ijde2020.11.1000108
Figure1: Metabolic and Haemodynamic factors contributing to
diabetic nephropathy
Risk factors for diabetic nephropathy
Risk factors for diabetic nephropathy include positive family
history, hyperglycemia, hypertension, smoking and others.
Genetics and ethnicity
There is a concordance of nephropathy among twins having T1DM
[17]. There is five times more chance to develop nephropathy in
diabetic siblings of patient with diabetes and nephropathy
[18].
Beneficial effects of ACE inhibition on nephropathy showed there
are high levels of ACE in patients with nephropathy and
diabetes,
especially abnormal alleles of ACE gene carriers [19].
ESRD is more common in ethnic groups like African Americans,
Mexican Americans and Native Americans [20].
Hyperglycemia
Hyperglycemia and duration of diabetes is a strong risk factor
of diabetic nephropathy [19]. In DCCT and other treatment trials
showed lowering glucose levels reduces DN [23]. Diabetic
nephropathy is not common in patients with HbA1c
-
Figure 6: Postsurgical photograpgh showing wide excision of
mass located in retromolar área.
Discussion
These type of tumours are very rare they comprise only 5% of
neoplasms and are seen in 0.4-2.6 for every 100,000 cases
around
the world, the mucoepidermoid tumour affects parotid and
minor
salivary glans in adults and is mostly seen in women and
Young
adults, most tof the cases arise in the the parotid gland with
this
ccase accounting for only 2-4% of the cases because it was seen
in
the submandibular gland, this patient is currently under
treatment
he was performed two sugeries for removal of ganglions
locanated
in neck and in the submandbullary gland, highes prevalence for
this
type of tumour is around the fifth decade of life and they can
be
asymptomatic like in this case with the patient having few to
no
symptoms. It has a puripotent cell origin and as we mention
can
be classidief into three stages [3].
References
Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
10.46715/ijde2020.11.1000108
Microalbuminuria/ a predictor of clinical complications
Urine albumin ranging from 30 to 300mg in a 24-h urine sample is
defined as Microalbuminuria [34, 36, 39].
Microalbuminuria (MA) and clinical complications
T1DM: It is an independent predictor of CV risks in patients
above the age of 45 years [35].
T2DM: It is considered to be the harbinger and strongly
associated with CV risks and mortality and morbidity [35].
Part of metabolic syndrome is also manifested by the levels of
microalbuminuria in association with other components
(metabolic
like lipids and BP, urate, body habitus and hs-CRP).
Association with SBP and CRP in causing endothelial dysfunction
[35, 37]
Elevated SBP is associated with generalized endothelial
dysfunction and leaky capillaries are associated with albumin
leak in the glomerulus and chronically inflamed endothelium.
Insulin Resistance
Central Obesity
Low levels of HDL Cholesterol
High Triglyceride levels
Systolic Hypertension
Lack of time dip in 24hr BP monitoring
Salt Sensitivity
Endothelial Dysfunction
Hypercoagulability
Impaired Fibrinolysis
Renal Dysfunction
Table 2: Showing the constellation of findings associated with
microalbuminuria [35]
Study Title
Number
of Subjects
Study Population
Mean Follow-up
Intervention
Renal outcomes seen with albuminuria to
RAAS blockade IDNT
1,715
Type 2 Diabetes,
hypertension
4 years
Irbesartan,
Amlodipine or Placebo
50% reduction in
proteinuria in the first year;
decrease in renal risk
RENAAL
1,513
Type 2 Diabetes
3.4 years
Losartan (50 mg or 100 mg) or
placebo
50% reduction in
albuminuria in the first six months: decreased risk for ESRD by
45%
MARVAL
332
Type 2 Diabetes
6 months
Valsartan vs Amlodipine
Urinary AER at 24 weeks was reduced more with
Valsartan
Table 3: Depicting the clinical trials of Albuminuria and renal
outcomes in T2DM [38]
Int Jou Diab&Endocrinol: IJDE-108 3
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Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
10.46715/ijde2020.11.1000108
Int Jou Diab&Endocrinol: IJDE-108 5
Study Title and design with interventions Gist of outcomes
Life study, Losartan studied in interventions Microalbuminuria
is associated with hypertension and CV
risks
TOMS, Treatment of mild HT study, Enalapril Reduction in
microalbuminuria along with BP control
PREVEND (Prevention of vascular and renal
end-stage disease)
Increase e-GFR with Microalbuminuria dure
to hyperfiltration and reduced GFR with macroalbuminuria
HOPE Increased CV risk and events with Microalbuminuria
Framingham Study Increased morbidity and mortality due to CV
disease
Copenhagen City Heart Study Microalbuminuria associated with
increased lipids and raised
BP with increased mortality
Table 4: Showing other studies related to microalbuminuria and
CV risk not totally related to diabetes [38, 39]
Framingham Heart Study, HOPE, LIFE, PREVEND, HARVEST, HOOM,
MONICA and Copenhagen city heart study emphasized the importance of
control of BP and Microalbuminuria (some using RAAS blockade) in
reducing the incidence of CV events and associated morbidity and
mortality.
Microalbuminuria can be useful screening method in assessing CV
risk in [35]
1) T2DM patients 2) >45 years older T1DM 3) Stage 2
Hypertension in elderly
Macroalbuminuria/a predictor of clinical complications
Macroalbuminuria predicts retinopathy, neuropathy and
cardiovascular disease.
Gall M et al, in their study showed 13.5% of T2DM had
macroalbuminuria. Arterial hypertension was prevalent in 85% and
ulcer of foot was seen in 25% [40].
Susan S et al, in a cross-sectional study involving 947 T2DM
patients from year 1990 to 1993. DN was prevalent in 75% among
macroalbuminuric patients. Among the patients who were suffering
from DN, proliferative retinopathy was detected in 49%. The
prevalence of neuropathy was also higher, 68% of patients with
macroalbuminuria was having neuropathy. Cardiovascular disease was
highly prevalent among those with macroalbuminuria, in 58% of the
patients. The study showed an independent association between
macroalbuminuria and occurrence of cardiovascular disease [41].
Diabetic nephropathy stages
First stage; Early, hyperfunction [42]
Characterized by hyperfunction
Structural changes; hyperplasia and hypertrophy of nephrons,
kidney size increased
GFR increased 20-40%
Blood pressure within normal
Albumin excretion is increased, and by physical activity
(provocation test) increased This stage is reversible by blood
sugar control (such as insulin treatment)
Second stage; Glomerular lesion without clinical finding
[42]
It develops over years. Structural changes; increased thickness
of basement membrane GFR increased 20-30% or normal Blood pressure
within normal Albumin excretion most of patients are within normal
and exercise test abnormal after years This stage is reversible by
blood sugar control.
-
Int Jou Diab&Endocrinol: IJDE-108 6
6
Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
10.46715/ijde2020.11.1000108
Third Stage; Incipient stage [42]
Structural changes not well studied. GFR still increased Blood
pressure increased Albumin excretion increased 25ug/min each
year
Fourth stage; Overt diabetic nephropathy [42]
Characterized by pronounced proteinuria Structural changes;
diffuse and nodular glomerulosclerosis and hyalinosis of arteriolar
GFR decreased Albumin excretion /progressive macroproteinuria Blood
pressure increased The antihypertensive treatment retards the
progression, aim of BP (140/85-90).
Fifth stage; End stage renal failure [42]
Characterized by glomerular closure GFR or = 90ml/min
Stage 2 GFR 98-60ml/min
Stage 3 GFR 59-30ml/min
Stage 4 GFR 29-15ml/min
Stage 5 GFR
-
Alternatives to UAE
Semi-quantitative dipstick measure of Micral Test II
albuminuria
Qualitative dipstick test for proteinuria Combur M, Boehringer
Manheim.
Quantitative measurement of protein in urine >430mg/l - 100%
sensitivity and 93%
spot sample specificity
24 urine protein collection >500mg/24h-confirms diagnosis
of
proteinuria
Table 7: Alternatives to UAE [50]
Prevent nephropathy; optimal glycaemic control, life style,
blood pressure and lipids control
Early management of hyperglycemia, hypertension, dyslipidemia
and smoking in diabetic patients, is very important to prevent or
delay the progression of DN [51].
Lifestyle measures include salt restriction, to stop smoking,
exercise and maintaining an ideal weight [52].
Improvement of glycemic control slows the progression and the
onset of microalbuminuria in both T1DM and T2DM. The HbA1c target
should be < 6.5 % and the greatest benefit comes from early and
better control [52].
Uncontrolled BP leads to progression of proteinuria and
deterioration of renal function. The recommended target BP is below
130/80 according to NICE guidelines in both T1DM and T2DM. ACEIs or
ARBs are the first drugs of choice and both can slow the
progression of DN [52].
Target LDL-C < 100 mg/dl and < 70 mg/dl in diabetic
patient and diabetic with CVD respectively. Collaborative
Atorvastatin Diabetes Study (CARDS) revealed a great reduction of
CVD and suggested that all DM patients should be on statins
[51].
Management of microalbuminuria [53]
Management of microalbuminuria involves intensive glycaemic
control which reduces the progression of the UAE in both T1DM
&T2DM patients.
Blood pressure control reduces the progression and development
of the albuminuria. Treatment with ACEI or ARB’s play a role by
reducing the intraglomerular pressure and decreases the
hyperfiltration, delays deterioration of the eGFR along with
reduction of the BP. Doses are increased to maximum tolerated and
approved dose with continuous monitoring of the creatinine and
potassium level. Monitoring for UAE to assess treatment response
and disease progression is required.
Other classes of antihypertensive therapy such as the Ca channel
blockers, beta blockers and diuretics are used along with ACEI or
ARBs for BP control.
Protein diet restriction delays the progression of albuminuria
and delays the deterioration of eGFR.
Management of macroalbuminuria [53]
Management of macroscopic albuminuria involves optimization of
glucose control, blood pressure, lipids and maintenance of
ideal
body weight through therapeutic life style modification/
reinforcement together with drug adjustment if needed, to
achieve
required target. Vaccination for HBV should be anticipated.
Monitoring for eGFR every 6 month for deterioration and
complications of Chronic kidney disease complications when
eGFR<
60ml/min/1.73m2; Hb, Urea, creatinine, potassium level, HCO3-,
Ca2+, PO2-, se albumin, and at least yearly parathyroid hormone
level, vit D level.
Adjustment for drug dose is required to achieve; target
glycaemia, blood pressure, lipid control, smoking cessation therapy
when
indicated and avoidance of hypotension.
Counseling regarding diet: Advise salt restriction (
-
Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
10.46715/ijde2020.11.1000108
Avoid medications that may deteriorate renal function or
stopping medications that are contraindicated according to the
stage of renal failure.
Management of different stages of diabetic nephropathy/
Nephrologist referral
There should be a multidisciplinary approach to managing
patients with diabetic nephropathy, focusing not only on slowing
progression but also on modifying cardiovascular risk factors [52].
DCCT trial showed that intensive management of diabetes could delay
microalbuminuria and slow the progression of microalbuminuria to
proteinuria [54].
Stage 1; No proteinuria
Lifestyle Modification Dietary control of CHO and fats and salt
restriction. Exercise and stop smoking Glycemic Control: Target
HbA1c 1 g/24hr) are indications for referral
[62].
Prognosis of Diabetic nephropathy
Diabetic nephropathy (DN) causes considerable morbidity and
mortality. In the US and Europe, DN is the major cause of end-stage
renal disease (ESRD) [63]. Both T1DM and T2DM develop ESRD, but
larger proportions affected are those with T2DM, due to the
increase in prevalence of T2DM. In T1DM with nephropathy, ESRD
accounts for 59-66% of mortality. The
growing prevalence of ESRD in Europe seen in type 1 diabetics
with proteinuria is 50%, while in Type 2 diabetics it is 3-11%, in
a period of 10years following the start of proteinuria. The
prediction of morbidity and mortality in DN is by Proteinuria. The
mortality rate was small and constant in those diabetics who had no
proteinuria while those diabetics with proteinuria had 40 times
increase in death rate. In a study done in Germany, the chances of
surviving for 5 years, in older type 2 diabetics was below 10%, and
around 40% in young type1 diabetics [64, 65].
The prognosis of DN in both T1DM and T2DM has been improving due
to the targeted approach, timely recognition of DN and managed
appropriately according to the stage.
Conclusion
Diabetic nephropathy is one of the commonest microvascular
complications of diabetes and is associated with other diabetes
related microvascular diseases. It affects 20-40% of people with
diabetes and is a leading cause of ESRD53. Interplay of multiple
environmental and genetic factors determines its development and
progression, the most important of these is uncontrolled
hyperglycaemia and hypertension. The hallmark of DN is the presence
of microalbuminuria in the early stages which progresses over a
variable period to macroalbuminuria and deterioration of the renal
function to ESRD requiring RRT.
Adequate control of blood glucose and hypertension are the
mainstay of management in addition to life style interventions
similar to those required to manage renal failure due to causes
[52].
Competing interests
The authors declared no competing interests regarding the
publication of the paper.
Authors Contribution
Sumon Rahman Chowdhury contributed to the study conception and
design, supervised the study, conducted data analysis and wrote the
manuscript. Reza Haider Chy and Tasnuva Tanzil planned the study
and prepared the first draft proposal. Alam Md. Sharif contributed
to the data analysis, supervised the study and critically revised
the manuscript.
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Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020)
Diabetic Nephropathy: A Comprehensive Review for Health Care
Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI:
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