Type 1 DM |
Type 2 DM |
Diabetes in Pregnancy |
Diabetic Ketoacidosis (DKA) Adults |
Hyperglycaemic Hyperosmolar State (HHS) |
Diabetic Nephropathy |
Diabetic Retinopathy |
Diabetic Neuropathy |
Diabetic Amyotrophy |
Maturity Onset Diabetes of the Young (MODY) |
Diabetes: Complications |
IgA Nephropathy (Berger's disease)
HIV associated nephropathy (HIVAN)
Balkan endemic nephropathy (BEN)
There is a nodular diabetic glomerulosclerosis with thickening of basement membranes, mesangial expansion and a Kimmelstiel–Wilson lesion which is pathognomonic of diabetic kidney disease.
- A complication of T1/2 Diabetes. 60% of TIDM over 30 years
- First signs: increased renal size/perfusion and microalbuminuria (30-300 mg/24 hrs)
- Hypertension accelerates renal damage
- Glomerular sclerosis
- Renal Papillary necrosis
- Chronic kidney disease
- Recurrent UTIs
- Arteriolar disease
- Hyporeninaemic hypoaldosteronism (raised potassium)
The following may suggest that worsening renal function is not due to diabetes
- Lack of retinopathy
- There is persistent haematuria or red cell casts
- Lack of micro or macro albuminuria
- Rapid deterioration
Microalbuminuria is when urine dipstick is positive for protein
but the urine albumin:creatinine ratio (UA:CR) is > 3mg/mmol
- Send an early morning urine sample. Microalbuminuria if UA:CR > 3 mg/mmol.
- UA:CR > 30 mg/mmol is consistent with overt nephropathy
- U&E with serum creatinine to calculate the estimated GFR.
- Diagnose CKD and manage appropriately. If the eGFR < 60 mL/min/1.73 m2 for 3 months or more, and/or Persistent proteinuria with urine ACRn > 3 mg/mmol, for 3 months or more.
- Kimmelstiel-Wilson lesion
- Nodular glomerulosclerosis
- Thickened GBM and Mesangial expansion
Steps in renal damage
- Hyperfiltration, Microalbuminuria
- Proteinuria, Falling GFR and ESRF
Management of CKD
- Screening identifies nephropathy in type 1/2 diabetes
- Classify the stage of CKD.
- Arrange monitoring/management, depending on the severity.
- Stop smoking, optimize blood glucose control with Hba1C
- Optimise lipid levels - Atorvastatin 20 mg OD
- BP control: ACEI/ARBs +/- Diuretic
- Refer Nephrology if UA:CR >7 ± GFR falling by >5mL/min/1.73m2/yr
- Renal replacement therapy: worsening GFR/Fluid overload/symptomatic uraemia.
- Renal transplantation: improves quality of life. Unusual for diabetic nephropathy to develop in the allograft.
- Pancreatic transplantation (with renal transplantation) can produce insulin independence and delay or reverse microvascular disease
- Ensure the person is aware of the 'sick-day rules' and which medications, if any, to temporarily stop if there is intercurrent illness or dehydration, to reduce the risk of acute kidney injury (AKI).