Diabetic nephropathy & lupus nephritis

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Teaching slides for Diabetic Nephropathy and Lupus Nephritis

Teaching slides for Diabetic Nephropathy and Lupus Nephritis

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  • 1.
    • Diabetic Nephropathy
    • &
    • Lupus Nephritis
    25/09/11 Dr (Brig) YD Singh Dr (Brig) YD Singh, MD, FIACM, DIT Professor (Internal Medicine) SKN Medical College & Gen Hospital Pune 411 041
  • 2. Diabetic Nephropathy: Introduction
    • The abnormal glycaemic milieu of diabetes
      • Related to microvascular complications
        • Causal relationship with hyperglycaemia is not linear
      • 30% develop clinically overt nephropathy.
      • Most patients with diabetes escape renal failure
        • Although some histological damage occurs in their kidneys
        • Their renal function remains essentially normal
      • Hyperglycaemia appears necessary
        • But not sufficient to cause Kidney damage & failure
    25/09/11 Dr (Brig) YD Singh
  • 3. Diabetic Nephropathy: Introduction
    • Diabetic nephropathy is the most common cause of ESRD world wide
      • Accounting for over 40% of dialysis patients
    • The 5-year mortality rate for a dialysis patient is 93%
    25/09/11 Dr (Brig) YD Singh
  • 4. Diabetic Nephropathy: Introduction 25/09/11 Dr (Brig) YD Singh Number of patients initiating Renal Replacement Therapy (RRT) for ESRD related to DM, 1984-2001 in USA
  • 5. Diabetic Nephropathy: Historic Note
    • Rolo (1798) Reported
      • Presence of protein in urine of DM pts
    • Bright (1836) Described
      • Seriousness of protein in urine of DM pts
    • Kimmelstiel, Wilson (1936 )
      • Described Nodular glomerular lesions in DM
    25/09/11 Dr (Brig) YD Singh
  • 6. Diabetic Nephropathy: Definition
    • DN is microvascular complication of DM
    • Characterized by:
      • Presence of Albuminuria
      • Elevated blood pressure
      • Declining glomerular function
    25/09/11 Dr (Brig) YD Singh
  • 7. Diabetic Nephropathy: Epidemiology
    • Type 1 Diabetic
    • 25 - 40% will develop nephropathy
    • 80 - 90% with micro-albuminuria
      • progress to overt DN in 5 - 10 years
    • Nearly 100% with gross proteinuria
      • Will progress to ESRD in 7 - 10 yrs
    25/09/11 Dr (Brig) YD Singh
  • 8. Diabetic Nephropathy: Epidemiology
    • Type 2 Diabetic
    • 50% have micro-albuminuria
      • at the time of presentation (secondary to HTN)
    • 10-20% with microalbuminuria
      • Will progress to overt nephropathy
    25/09/11 Dr (Brig) YD Singh
  • 9. Diabetic Nephropathy: Risk Factors
    • Age, Race, Ethnicity
    • History of microalbuminuria
    • Hypertension
    • Poor glycaemic control
    • Smoking
    • Family history of nephropathy
      • Genetic abnormalities of ACE gene
    25/09/11 Dr (Brig) YD Singh
  • 10. Diabetic Nephropathy: Stages
    • Stage I – Hyperfiltration
      • Increased blood flow in the kidney,
      • Early renal hypertrophy
    • Stage II - Glomerular lesions
      • Without clinically evident disease
    • Stage III - Incipient nephropathy with microalbuminuria
      • Alb/Cr ratio 0.03 - 0.3 or
      • Albumin 20-200 mcg/min on timed specimen
    25/09/11 Dr (Brig) YD Singh
  • 11. Diabetic Nephropathy: Stages
    • Stage IV - Overt diabetic nephropathy
      • With proteinuria >500 mg/24 hr
      • Creatinine clearance <70 ml/min
    • Stage V – End stage renal disease (ESRD)
      • Creatinine clearance <15 ml/min
      • Creatinine = 6mg/dl
    25/09/11 Dr (Brig) YD Singh
  • 12. Diabetic Nephropathy: Stages 25/09/11 Dr (Brig) YD Singh I II III IV V
  • 13. Incipient Nephropathy
    • Type 1 Diabetes
    • 2 out of 3 urine tests + for microalbuminuria
      • Screening should start 5 yrs after initial Δ
    • Presence of proliferative Diab Retinopathy
    • 80-90% of patients with microalbuminuria
      • Will progress to Diab Neuropathy
    25/09/11 Dr (Brig) YD Singh
  • 14. Incipient Nephropathy
    • Type 2 Diabetes
    • 2 out of 3 urine tests + for microalbuminuria
      • Start screening at the time of diabetes Δ
    • Presence of diabetic retinopathy
      • 20-30% may have diabetic nephropathy but not diabetic retinopathy
    • 25% may have a diagnosis of nephropathy other than diabetic nephropathy
    25/09/11 Dr (Brig) YD Singh
  • 15. Overt Diabetic Nephropathy
    • Gold Standard is biopsy
    • Diagnosis can be made
      • By clinical history and
      • Exclusion of other renal disease
    • Workup includes
      • Renal ultrasound
        • For size, shape, abnormalities
      • 24 hour urine for total protein and
        • Creatinine clearance
    25/09/11 Dr (Brig) YD Singh
  • 16. Diabetic Nephropathy: Morphological Changes
    • Glomerular & tubular hypertrophy
    • Thickening of GBM & TBM
    25/09/11 Dr (Brig) YD Singh A .Normal capillary wall thickness B. Severe capillary wall thickening A B
  • 17. Diabetic Nephropathy: Morphological Changes 25/09/11 Dr (Brig) YD Singh Mesangial expansion is the morphological lesion that closely related to the evolution of the GFR
  • 18. Diabetic Nephropathy: Morphological Changes 25/09/11 Dr (Brig) YD Singh Nodular lesion in Type 1 DM (Kimmelstiel Wilson Lesion)
  • 19. Diabetic Nephropathy: Morphological Changes
    • Glomerular & tubular hypertrophy
    • Thickening of GBM & TBM
    • Mesangial expansion
    • Nodular & Diffuse glomerulosclerosis
    • Arteriosclerosis and hyalinosis of a.a & e.a
    • Tubulointerstitial fibrosis
    25/09/11 Dr (Brig) YD Singh
  • 20. Diabetic Nephropathy: Treatment
    • Lifestyle changes
      • Lose weight
      • Stop smoking
      • Low salt diet for BP control
      • Low protein diet?
    • Glycaemic Control
      • Benefit in both Type 1 and Type 2 patients
      • Recommended: HbA1C <6.5 - 7.0 %
    25/09/11 Dr (Brig) YD Singh
  • 21. Diabetic Nephropathy : HbA1C 25/09/11 Dr (Brig) YD Singh UK Prospective Diabetes Study
  • 22. Diabetic Nephropathy: Treatment
    • Blood Pressure control
      • Current recommendations for BP <130/80-85
      • If nephropathy BP <125/75
    • Several randomized controlled trials
      • Indicate improved blood pressure control
        • Decreases rate of progression of renal disease
        • In both type 1 & type 2 patients
    25/09/11 Dr (Brig) YD Singh
  • 23. Diabetic Nephropathy: Treatment
    • ACE inhibitors & ARBs use
      • Decrease microalbuminurea
      • Improve diabetic nephropathy
    • Mechanism of action
      • ACE-inhibitors limit angiotensin II production
        • By blocking angiotensin converting enzyme
        • ARB-agents block angiotensin II receptors
    25/09/11 Dr (Brig) YD Singh
  • 24. Diabetic Nephropathy: Protein Restriction
    • 0.8 g/kg/day in
      • Overt nephropathy
    • 0.6 g/kg/day in
      • Diabetics with falling GFR
    25/09/11 Dr (Brig) YD Singh
  • 25. Diabetic Nephropathy: Management Summary (1)
    • Annual screening for microalbuminuria
    • ACEI, ARBs Regardless of BP level
    • BP control <135/80 - <125/75 (2-3 drugs)
    • Intensive glycemic control (HB A1c <7%)
    • Smoking cessation
    • Prevent radiocontrast nephropathy
    • Restrict dietary protein (0.8-0.6 g/kg/d)
    • Control dyslipidemia (LDL- C <100 mg/dl)
    25/09/11 Dr (Brig) YD Singh
  • 26. Diabetic Nephropathy: Management Summary (2)
    • At GFR 25 ml/m
      • Vascular access be established
    • At GFR 15-20 ml/m
      • RRT should start
    • In all patients of Type 1 DM
      • Renal / Pancreas Transplant to be considered
    25/09/11 Dr (Brig) YD Singh
  • 27. Thank U 25/09/11 Dr (Brig) YD Singh