1. Diabetic nephropathy is a common cause of kidney disease in patients with diabetes and involves 5 phases that can progress to kidney failure if not controlled. 2. Risk factors include poor blood sugar control, long duration of diabetes, and hypertension. 3. Progression can be slowed by good control of blood pressure and blood sugar as well as use of ACE inhibitors. Regular screening is important for early detection and treatment.

1. Nephrotic syndrome with bland
urine sediment
( (pure nephrotic

2. Minimal Change Nephrotic
( Syndrome. MCNS (Nil lesion
It‘s the most common type of NS. in children-
< 90% of all children with NS have this condition
usual age : 2 – 6 years, with a male –female
ratio of 2:1
Account for about 15 - 25% of adult patients with-
NS with equal male-female ratio .some adults
with malignant neoplasm have developed
.MCNS. as Hodgkin‘s lymphoma
.Usually present as sudden onset of NS in children

3. MCNS does not progress to renal •
impairement ,the main problems are those
of nephrotic syndrome & complications of
(treatment (steroid
•
Histopathology
.( Light microscopy is normal ( nil lesion-
Electron microscopy shows fusion of-
.podocyte foot processes
.

4. Teatment
A-.treatment of proteinuria
B-.treatment of complications of NS
.C- steroid & other immunosupressant drugs
.( no need for nenal biopsy( NS in children-
most children with NS have good response to-
steroid( prednisolone 1 mg/kg/day for 6wks ,then tapered
.( over 4-6 months
If the patient have no response to sreroid do renal
biopsy(may be other pathology as focal segmental
.( glomerulosclerosis
Prognosis. : good

5. Membranous Glomerulopathy
.It‘s the most common cause of NS in adults
There is nephrotic range proteinuria with bland
.urinary sediment
Histopathology
Thickening of GBM with granular deposits of IgG &
complement.

6. Aetiology •
.A- Primary ( Idiopathic ( :The most common cause •
B- Secondary •
nfection.: hepatitis B , syphilisI- •
Neoplasm: carcinoma of lung, stomach- •
breast
Drugs: captopril , gold , D-penicillamine- •
disease:SLE,rheumatoidCollagen vascular- •
. arthritis •

7. Prognosis
one-third remit spontaneously( spontaneous -
(remission
. one-third remain in nephrotic state -
.one-third show progressive loss of renal function -
-

8. Management -
A-good prognostic features)need )conservative manag -
.children- -
adults with non-nephrotic range proteinuria- -
women younger than 40 years old with NS but with- -
)normal renal function.&modest proteinuria)>9gm/d -
B-poor prognostic features)need specific treatment -
) like steroid & cytotoxic agents -
) persisting severe proteinuria )<9gm/day- -
.men older than 40 years with symotomatic NS- -
. progressive renal failure- -

9. Management of membranous Glomerulopathy
A- Treatment of proteinuria
.B- Treatment of complications of NS
C- Steroid & other immunosupressant drugs

10. Focal Segmental Glomerulosclerosis
, Can occurs in children & adults
Histopathology
Focal & segmental collapse of capillary loops
&mesangial sclerosis
Aetiology
.A-primary (idiopathic (,collapsing glomerulopathy
B-secondary, -Heroin abuse
AIDS-
.Reflux nephropathy -

11. Collapsing Glomerulopathy
.more common in black people-
.massive proteinuria-
.rapid progression to renal failure-
.Prognosis of focal segmental glomerulosclerosis
.Have poor prognosis
progress to chronic renal failure.(by about 10 60-70%
) years

12. Management of membranous Glomerulopathy
A- Treatment of proteinuria
.B- Treatment of complications of NS
C- Steroid & other immunosupressant drugs

13. Diabetic Nephropathy

14. Diabetic Nephropathy
:Renal complications of diabetes mellitus
.diabetic nephropathy-1
.frequent urinary tract infection-2
autonomic neuropathy,may impaire bladder-3
function& increase the risk of ascending
.infection

15. : Effects of renal impairment on DM
diabetic control become more difficult in renal-1
impairment.( may develop hypoglycemia more
.( frequently
Isuline requirement decrease in diabetic patiens-2
with renal impairment , due to decrease tubular
.metabolism of insuline
In renal failure it‘s better to avoid using metformine-3
. & long acting sulphonylurea

16. Diabetic Nephropathy
Diabetic nephropathy is an important cause of morbidity
&mortality,&is among the most common cause of ESRD
About 30% of patients with type 1 diabetes have
.developed diabetic nephropathy after 20 years
Risk factors for developing diabetic nephropathy
.poor control of blood sugar -1
.long duration of diabetes -2
presence of other microvascular complications-3
.pre-existing hypertention-4
family history of diabetic nephropathy-5
.family history of hypertention-6

17. Phases of diabetic nephropathy
: There are 5 phases of diabetic nephropathy
Phase 1
Hyperfiltration , with an increased glomerular
filtration rate (GFR( & renal hypertrophy .the
GFR then return to normal
This phenomenon is associated with an increase
in intraglomerular pressure ( if persist may cause
.( proteinuria in the future

18. .Phase 2
In this phase the patient may gradually develop
glomerulosclerosis , with thickening of the
glomerular capillary basement membrane &
expantion of the collagen matrix within the
mesangial region .
Albumin excretion remains normal (< 30 mg/24 hr.( .
Many diabetic patiens develop this , but, Progression
to ESRD occur in those with poor glycemic control .

19. Phase 3
In this phase there is.microalbuminuria
Microalbuminuria is defined as an albumin excretion rate of
.30 – 300 mg/ 24 hr
During this phase of nephropathy , patients usually initially
have a normal GFR, which begins to fall as the
.microalbuminuria increases
Approximately 80% of patients with sustained
microalbuminuria will develop clinical diabetic nephropathy
. over the next 7 to 14 years
: The decline into renal failure can be slowed by
.good control of blood glucose level -1
.good control of hypertention -2
.use of angiotensin-converting enzyme inhibitors -3

20. Phase 4
, In this phase there isdipstick positive proteinuria
. ( this correlates with an albumin excretion rate <300 mg/24hr(
& During this phase , a progressive fall in GFR occurs
. hypertension is common
: Progression to renal failure can be slowed by
. good control of hypertention-1
.use of ACE-inhibitors-2
low – protein diet (0.6 to-3.) 0.8 g./kg./day
maintenance of near-euglycemia for prevention of diabetic*
nephropathy is of less benefit ,since diabetic nephropathy is
.now well established

21. Phase 5
End-stage renal disease . Occurs in most
patients who develop clinical proteinuria due to
. diabetic nephropathy
.Dialysis is usually started at a GFR of 15 ml/min
Diabetic patients should be referred to a
nephrologist when the serum creatinine rises
above 3mg/dl.(discussion regarding the need for
hemodialysis versus peritoneal dialysis versus
.( transplantation

22. Histopathologically there are 2 types of
: diabetic nephropathy
.Diffuse glomerulosclerosis-1
Nodular glomerulosclerosis-2
.(kimmelstiel – wilson nodule(

23. :Natural history of diabetic nephropathy
In the first few years of DM there is hyperfiltration-
which declines to return to normal at about 10
.years
. After about 10 years there is sustained proteinuria-
By approximately 14 years it has reached nephrotic-
.range proteinuria
. ESRDAt approximatelly 16 years it reach-

24. Screaning for microalbuminuria
In type 1 DM screaning for microalbuminuria
should be started annually from 5 years after
.diagnosis
In type 2 DM screaning should be started annually
.from time of diagnosis
Other causes of proteinuria should be excluded as
fever , exercise , heart failure , UTI ,prostatism ,
. menstruation

25. `
Progression of diabetic nephropathy can
: be reduced by
.improve control of blood glucose -1
Aggressive reduction -2 .of blood pressure
Use ACEI therapy .(calcium channel blockers -3
.( are the alternatives
Microalbuminuria in type 1 DM indicate the
presence of diabetic nephropathy & should be
treated with ACE inhibitors regardless of wether
. blood pressure is elevated or not