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Diabetic Nephropathy Dr Mohamed  Alamin Nephrology and Renal Transplant Specialist KAAH & OC Jiddah KSA
بسم الله الرحمن الرحيم
Diabetic  Nephropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],Diabetic  Nephropathy
Diabetic  Nephropathy USRDS 2006
Diabetic  Nephropathy Saudi Arabia 2006
DN: Diagnosis What are the Diagnostic Criteria ? Who are the Susceptible Patients ?
DN: Diagnosis What are the Diagnostic Criteria ? Who are the Susceptible Patients ?
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN:  Susceptibility / Risk Factors
|} ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN:  Susceptibility / Risk Factors
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN:  Susceptibility / Risk Factors
Diabetic Patient   IN Development Of In The Presence Of Diabetic Retinopathy  Hypertension  Progressive Renal Deterioration   Absence of other causes  P ersistant Proteinuria  > 300 mg / day DN: Diagnostic Criteria  Type 1> 10 Y Type 2 at Diagnosis
1.  Duration of Diabetes in DN Average  Type 1:  Overt DN Rarely occur before 10 yrs. Type 2:  May be present in newly diagnosed patients   .   Peak   Peak incidence    10 to 20 y duration   If duration > 30 y + Normoalbuminuria Risk is Very Low DN: Diagnostic Criteria  Decline   After 20 y    Progressive decline in incidence takes place.
Normal Protein  in urine  should not exceed  150 mg /day 2.  Abnormal Urinary Albumin Excretion DN: Diagnostic Criteria
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],2.  Abnormal Urinary Albumin Excretion DN: Diagnostic Criteria
The structural damage  in DN leads to  Albumin in urine = Albuminuria 2.  Abnormal Urinary Albumin Excretion DN: Diagnostic Criteria
[object Object],[object Object],[object Object],2.  Abnormal Urinary Albumin Excretion DN: Diagnostic Criteria
[object Object],[object Object],[object Object],3.  Retinopathy In Type 1 Diabetes In Type 2 Diabetes ,[object Object],[object Object],[object Object],DN: Diagnostic Criteria
3.  Retinopathy DN: Diagnostic Criteria
3.  Retinopathy DN: Diagnostic Criteria
Higher levels of blood pressure are associated with more rapid progression of diabetic kidney disease   Most patients with diabetic kidney disease  are hypertensive   Hypertension is both a cause and a consequence of renal disease and the kidney is both villain and victim in hypertension.   Critchley JA et al. Chin Med J (Engl). 2002 Jan;115(1):129-35. 4.  Hypertension DN: Diagnostic Criteria
4.  Hypertension DN: Diagnostic Criteria  With Macroalbuminuria: >90% With Microalbuminuria: 80% At Diagnosis: 50% Type 2 With Macroalbuminuria: 65-88% With Microalbuminuria: 30-50% At Diagnosis: 20-40% Type 1
[object Object],[object Object],[object Object],In Type 1 Diabetes ,[object Object],[object Object],[object Object],[object Object],In Type 2 Diabetes 4.  Hypertension
[object Object],[object Object],[object Object],4.  Hypertension Systolic Or Diastolic
4.  Hypertension Effect On Glomerulus Hypertension Dilatation of Afferent Arteriole Increase Intraglomerular Pressure Hyperfiltration Hemodynamically Mediated Damage Evans CT. Clin Diab. VOL. 18 NO. 1   2000
[object Object],[object Object],[object Object],4.  Hypertension Strong Or The Strongest  Aggravating Factor For DN ,[object Object],[object Object],[object Object],[object Object]
4.  Hypertension Strong Or The Strongest  Aggravating Factor For DN
[object Object],[object Object],[object Object],5.  Progressive Deterioration  of RF DN: Diagnostic Criteria
5.  Progressive Deterioration  of RF DN: Diagnostic Criteria
Causes that may    Urinary Albumin ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],6.  Exclusion of Other Causes DN: Diagnostic Criteria
Lack of Retinopathy or Neuropathy Persistent Hematuria (microscopic or  macroscopic) Signs or symptoms of Systemic Disease Rapidly Rising Creatinine  High SCr with little or no Proteinuria F/H of Nondiabetic Renal Disease (e.g.  polycystic kidney disease or Alport  syndrome) Short Duration of Diabetes 6.  Exclusion of Other Causes Markers of Non Diabetic Renal Diseases Indications of Renal Biopsy in Diabetes 1 2 3 4 5 6 7
Diabetic  Nephropathy Pathogenesis of DN
Intra glomerular HTN Hyperperfusion Aff VD/ Eff VC Hyperfiltration Polyol Pathway Protein Kinase C GF, Cytokines(TGF-B) ROS  Gl.Hydrolic Pressure Endothelial Dysfunction Angitensin II Glucotoxicity Structural Changes Metabolic Changes Functional Changes AGEs    Renal Plasma Flow Glomerulosclerosis Thickening of GBM Mesangial Expansion Hyperglycemia Renal Hypertrophy
DN: Pathogenesis
DN: Pathogenesis
Diabetic  Nephropathy Stages of DN
<30mg/day 30-300mg/day >300mg/d DN: Stages
Natural History of Type 1 Diabetic Nephropathy DN: Natural History
Susceptibility Silent Silent Incipient Overt ESRD DN: Natural History   Natural History of Type 2 Diabetic Nephropathy
Diabetics with Macroalbuminuria are More Likely to Die than Develop ESRD C V D E A T H The United Kingdom Prospective Diabetes Study (approx. 5000 Type 2 Diabetics)  Newly diagnosed, predominantly white, medically treated  Adler et al.  Kid Int, 2003 Elevated Serum Creatinine 19% No albuminruia 1.4% Microalbuminruia 3.0% Macroalbuminruia 4.6%
Diabetic  Nephropathy Death Rate In Diabetic Patients on RRT 54.1
Causes of Death DN: Causes of Death   Stroke Myocardial Infarction Heart Failure Sudden Death
[object Object],[object Object],DN: Prognosis
Microalbuminuria Macroalbuminuria 80%/10-15y Macroalbuminuria ESRD 50%/ 10y 75%/ 20y Without Specific Interventions in type 1 DM Microalbuminuria Macroalbuminuria Macroalbuminuria ESRD 20%/ 20y Without Specific Interventions in type 2 DM 20-40 % American Diabetic Association. Diab Care 2004 DN: Prognosis
DN:  Where to Meet the Patients? Susceptibility Silent Silent Incipient Overt ESRD Screening and Prevention of Type 2 Diabetes Screening and Prevention of Diabetic Nephropathy Natural History of Type 2 Diabetic Nephropathy Prevention of progression of MiA to overt DN
Preventive/ Pre-emptive  Strategies Screening For DN Prevention Of DN
1 American Diabetes Association:   Nephropathy in Diabetes   (Position Statement).  Diabetes Care  27 (Suppl.1): S79-S83, 2004 BP UAE Lipid At Least Annually < 150mg/dl  TG < 100 mg/dl  LDL > 40mg/dl  HDL DN: Screening
DN: Screening
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN: Screening
DN: Screening
Dietition Endocrinologist Physician Trained Diabetes Nurse General Practitioner Multiseciplinary Approach Prevention Of DN   Requirements DN:  Prevention/Preemptive St.
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Target Diabetic Populations DN:  Prevention/Preemptive St.
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Measures DN:  Prevention/Preemptive St.
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Measures DN:  Prevention/Preemptive St.
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Measures DN:  Prevention/Preemptive St.
Treatment of Overt DN
The Renal Injury Triad Angiotensin II Proteinuria Hypertension In Diabetes Smoking Hyperlipidemia Hyperglycemia Dietary protein
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN: Treatment
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN: Treatment
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN: Treatment
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN: Treatment
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DN: Treatment
[object Object],DN: Treatment
[object Object],[object Object],DN:  Novel Therapeutic Strategies
[object Object],[object Object],[object Object],DN:  Novel Therapeutic Strategies
Referrences ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],Antihypertensive Drugs in DKD
[object Object],[object Object],Antihypertensive Drugs in DKD
[object Object],[object Object],[object Object],Antihypertensive Drugs in DKD
[object Object],[object Object],[object Object],[object Object],Antihypertensive Drugs in DKD
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Antihypertensive Drugs in DKD
[object Object],[object Object],Role of Spironolactone
[object Object],[object Object],Role of Spironolactone
Role of Spironolactone
Role of Spironolactone
THANKS Dr. Mohamed Alamin

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Diabetic Nephropathy 1

  • 1. Diabetic Nephropathy Dr Mohamed Alamin Nephrology and Renal Transplant Specialist KAAH & OC Jiddah KSA
  • 3.
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  • 5. Diabetic Nephropathy USRDS 2006
  • 6. Diabetic Nephropathy Saudi Arabia 2006
  • 7. DN: Diagnosis What are the Diagnostic Criteria ? Who are the Susceptible Patients ?
  • 8. DN: Diagnosis What are the Diagnostic Criteria ? Who are the Susceptible Patients ?
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  • 12. Diabetic Patient IN Development Of In The Presence Of Diabetic Retinopathy Hypertension Progressive Renal Deterioration Absence of other causes P ersistant Proteinuria > 300 mg / day DN: Diagnostic Criteria Type 1> 10 Y Type 2 at Diagnosis
  • 13. 1. Duration of Diabetes in DN Average Type 1: Overt DN Rarely occur before 10 yrs. Type 2: May be present in newly diagnosed patients . Peak Peak incidence  10 to 20 y duration If duration > 30 y + Normoalbuminuria Risk is Very Low DN: Diagnostic Criteria Decline After 20 y  Progressive decline in incidence takes place.
  • 14. Normal Protein in urine should not exceed 150 mg /day 2. Abnormal Urinary Albumin Excretion DN: Diagnostic Criteria
  • 15.
  • 16. The structural damage in DN leads to Albumin in urine = Albuminuria 2. Abnormal Urinary Albumin Excretion DN: Diagnostic Criteria
  • 17.
  • 18.
  • 19. 3. Retinopathy DN: Diagnostic Criteria
  • 20. 3. Retinopathy DN: Diagnostic Criteria
  • 21. Higher levels of blood pressure are associated with more rapid progression of diabetic kidney disease Most patients with diabetic kidney disease are hypertensive Hypertension is both a cause and a consequence of renal disease and the kidney is both villain and victim in hypertension. Critchley JA et al. Chin Med J (Engl). 2002 Jan;115(1):129-35. 4. Hypertension DN: Diagnostic Criteria
  • 22. 4. Hypertension DN: Diagnostic Criteria With Macroalbuminuria: >90% With Microalbuminuria: 80% At Diagnosis: 50% Type 2 With Macroalbuminuria: 65-88% With Microalbuminuria: 30-50% At Diagnosis: 20-40% Type 1
  • 23.
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  • 25. 4. Hypertension Effect On Glomerulus Hypertension Dilatation of Afferent Arteriole Increase Intraglomerular Pressure Hyperfiltration Hemodynamically Mediated Damage Evans CT. Clin Diab. VOL. 18 NO. 1 2000
  • 26.
  • 27. 4. Hypertension Strong Or The Strongest Aggravating Factor For DN
  • 28.
  • 29. 5. Progressive Deterioration of RF DN: Diagnostic Criteria
  • 30.
  • 31. Lack of Retinopathy or Neuropathy Persistent Hematuria (microscopic or macroscopic) Signs or symptoms of Systemic Disease Rapidly Rising Creatinine High SCr with little or no Proteinuria F/H of Nondiabetic Renal Disease (e.g. polycystic kidney disease or Alport syndrome) Short Duration of Diabetes 6. Exclusion of Other Causes Markers of Non Diabetic Renal Diseases Indications of Renal Biopsy in Diabetes 1 2 3 4 5 6 7
  • 32. Diabetic Nephropathy Pathogenesis of DN
  • 33. Intra glomerular HTN Hyperperfusion Aff VD/ Eff VC Hyperfiltration Polyol Pathway Protein Kinase C GF, Cytokines(TGF-B) ROS  Gl.Hydrolic Pressure Endothelial Dysfunction Angitensin II Glucotoxicity Structural Changes Metabolic Changes Functional Changes AGEs  Renal Plasma Flow Glomerulosclerosis Thickening of GBM Mesangial Expansion Hyperglycemia Renal Hypertrophy
  • 36. Diabetic Nephropathy Stages of DN
  • 38. Natural History of Type 1 Diabetic Nephropathy DN: Natural History
  • 39. Susceptibility Silent Silent Incipient Overt ESRD DN: Natural History Natural History of Type 2 Diabetic Nephropathy
  • 40. Diabetics with Macroalbuminuria are More Likely to Die than Develop ESRD C V D E A T H The United Kingdom Prospective Diabetes Study (approx. 5000 Type 2 Diabetics) Newly diagnosed, predominantly white, medically treated Adler et al. Kid Int, 2003 Elevated Serum Creatinine 19% No albuminruia 1.4% Microalbuminruia 3.0% Macroalbuminruia 4.6%
  • 41. Diabetic Nephropathy Death Rate In Diabetic Patients on RRT 54.1
  • 42. Causes of Death DN: Causes of Death Stroke Myocardial Infarction Heart Failure Sudden Death
  • 43.
  • 44. Microalbuminuria Macroalbuminuria 80%/10-15y Macroalbuminuria ESRD 50%/ 10y 75%/ 20y Without Specific Interventions in type 1 DM Microalbuminuria Macroalbuminuria Macroalbuminuria ESRD 20%/ 20y Without Specific Interventions in type 2 DM 20-40 % American Diabetic Association. Diab Care 2004 DN: Prognosis
  • 45. DN: Where to Meet the Patients? Susceptibility Silent Silent Incipient Overt ESRD Screening and Prevention of Type 2 Diabetes Screening and Prevention of Diabetic Nephropathy Natural History of Type 2 Diabetic Nephropathy Prevention of progression of MiA to overt DN
  • 46. Preventive/ Pre-emptive Strategies Screening For DN Prevention Of DN
  • 47. 1 American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004 BP UAE Lipid At Least Annually < 150mg/dl TG < 100 mg/dl LDL > 40mg/dl HDL DN: Screening
  • 49.
  • 51. Dietition Endocrinologist Physician Trained Diabetes Nurse General Practitioner Multiseciplinary Approach Prevention Of DN Requirements DN: Prevention/Preemptive St.
  • 52.
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  • 57. The Renal Injury Triad Angiotensin II Proteinuria Hypertension In Diabetes Smoking Hyperlipidemia Hyperglycemia Dietary protein
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