Diabetic Nephropathy

What is it?

Diabetes has now become a common cause of end-stage kidney failure in the United States and Europe, with diabetics accounting for 40% of new dialysis cases in the United States and 17% in Europe. Although preventive measures appear to be increasingly effective in reducing the development of this complication in people with diabetes, the steady increase in the number of diabetic patients must be considered. Diabetic nephropathy is a microvascular complication of diabetes that affects about a third of diabetic patients and causes kidney failure. Hyperglycemia plays a key role in the onset and progression of diabetic nephropathy through both metabolic and hemodynamic mechanisms. Alongside with the role of hyperglycemia, the fundamental contribution of arterial hypertension is now recognized, especially to kidney damage in type 2 diabetes, with which hypertension itself is often associated. Kidney damage is predominantly glomerular and ends in nodular or diffuse glomerulosclerosis. Diabetes-associated vasculopathy can also affect the kidneys, reducing their functionality.

Which are the symptoms?

At the clinical level, diabetic nephropathy is characterized by a triad: proteinuria, decreased glomerular filtration, and hypertension. Proteinuria is assessed by measuring albuminuria: in the early stage of the disease, abnormal levels of albumin in the urine appear (less than 30 mg/day). This condition is called microalbuminuria. In the absence of specific therapeutic interventions, approximately 80% of diabetic patients have increased urinary albumin excretion, which in some of them may develop to excrete more than 500 mg of albumin within 24 hours, with progression to full nephropathy or persistent clinical proteinuria. After the initial phase of increased hyperfiltration, glomerular filtrate returns to normal and then gradually decreases until the terminal stage of kidney failure. Aerodynamic hypertension is usually secondary to kidney damage in type 1 diabetes; in the case of type 2 diabetes, it usually precedes and contributes to the development of the complication.

  • edema
  • arterial hypertension
  • increased creatinine
  • proteinuria

How is it diagnosed?

Screening, diagnosis, and staging of diabetic nephropathy are based on the measurement of urinary albumin. This can be done based on a spot urine sample or 24-hour urine collection. In the first case, the albumin concentration must be normalized to the creatinine concentration and expressed as an albumin/creatinine ratio. Urinalysis is necessary since it provides additional information, especially with regard to urine sediment analysis. Renal ultrasonography can be used in patients with chronic stage 3 kidney failure or higher to obtain morphologic information on the kidneys, measure their size, detect any abnormalities of the kidneys and urinary tract, and measure the cortico-midullary ratio. 

Suggested exams

How is it treated?

Prevention and treatment are based on good control of glycemia, blood pressure, and lipids. These measures, especially when taken from the beginning of the disease, have proven effective in the primary and secondary prevention of diabetic nephropathy. Smoking cessation and a low-protein diet are also effective in slowing the progression of end-stage kidney failure.

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