Diabetes and renal disease

Posted by e-Medical PPT
Causes of renal disease in diabetes
Diabetic nephropathy
Renal artery stenosis
Myeloma, outflow obstruction, polycystic renal disease, glomerulonephritis, etc
Drugs
 NSAIDS/Cox 2 inhibitors
 Fibrates
 ACEI, ARBs

Diabetic Nephropathy
30% of all end-stage renal disease
Increased co-morbidity and mortality – retinopathy, cardiovascular disease, stroke, peripheral vascular disease
May be prevented/delayed by early screening and treatment

Diabetic nephropathy in type 1 diabetes
Seldom occurs in first 5 years of diabetes
Peak incidence after 15-17 years of diabetes
Following the onset of persistent proteinuria, 25% develop renal failure in 6 years and 75% in 15 years.
Associated with high risk of macrovascular disease

Diabetic nephropathy in type 2 diabetes
May be present at diagnosis
Prevalence of proteinuria 7-10% after 5 years of diabetes and 20-35% after 20-25 years
Most patients die of heart disease or stroke before reaching end-stage renal failure

Estimated (e)GFR (using MDRD equation)
an estimate ofGFR, based on serum creatinine, age, sex and race corrected for body surface area
Normal = 100 ml/min/1.73m2
Wide confidence intervals. Most likely to be inaccurate in malnourished, amputees etc
Not so good near normal (slightly low values should not be overinterpreted)
Underestimates by 20% in Afro-Caribbeans
Creatinine must be stable
Not valid for under 18s, pregnant women

Initial assessment of patient with diabetes and renal impairment
Is this likely to be diabetic nephropathy?
Presence of retinopathy
Microalbuminuria/proteinuria

Is this likely to be renal artery stenosis?
Family history, Drug history, GU history etc
AIP, myeloma screen, PSA
Ultrasound

Renal Artery Stenosis Clinical features and pointers to diagnosis
Peripheral vascular disease, male, smoker
Resistant hypertension
Deteriorating renal function in hypertensive patient, especially on ACE/ARB
Renal impairment with minimal proteinuria
“Flash” pulmonary oedema
>1.5cm difference in renal size on U/sound..

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