The document discusses diabetic nephropathy, which is a long-term complication of diabetes characterized by proteinuria, declining kidney function, and hypertension. It notes that diabetes is a growing global health problem affecting over 425 million people currently. Screening and early intervention can help prevent or slow the worsening of kidney function in diabetic nephropathy. The key is maintaining good glycemic control as well as controlling blood pressure and cholesterol.

1. Nefropati Diabetik
Seminar Temu Alumni FKUGM-83
Yogyakarta, 28 Pebruari 2020

2. Diabetes is a global heath
challenge1,2
425 MILLION2
PATIENTS
2000 20452015
736 MILLION2
PATIENTS
177 MILLION1
PATIENTS
73%
INCREASE
Diabetes is expected to grow 73% by 2045
References: 1. International Diabetes Federation. IDF Diabetes Atlas, 2 ed. Brussels, Belgium: International Diabetes
Federation, 2003. 2. International Diabetes Federation. IDF Diabetes Atlas, 8ed. Brussels, Belgium: International
Diabetes Federation, 2017. 3. Harris S et al., Glycemic control and morbidity in the Canadian primary care setting
(results of the diabetes in Canada evaluation study). Diabetes Research and Clinical Practice 2005; 70:90–97. 4. UK
Prospective Diabetes Study (UKPDS) Groups. Lancet 1998: 352 (9131):837-53. 5. The Diabetes Control and
Complications Trial Research Group. N Engl J Med 1993;329(14):977-86.
Only ONE in TWO adults with diabetes know
that they have diabetes.1
Many patients have poor glycaemic control –
and poor control can lead to costly, life-
threatening complications2-4:
AMPUTATIONS
HEART DISEASE KIDNEY FAILURE
BLINDNESS

3. RISKESDAS 2018: 10,9% Prevalence of DM in Indonesia

5. 5

7. Pengertian
 Laju Filtrasi Glomerolus ( LFG, GFR
: Glomerular Filtration Rate) :
Jumlah volume darah (serum) yang
dibersihkan oleh ginjal per-unit waktu (
ml/ menit)
 Menghitung LFG :
1. Dengan Rumus (Cockcroft
Gault)
2. Aplikasi ( aplikasi android ,iOS)

8. Penyakit ginjal kronik
(PGK) : kerusakan atau
penurunan fungsi ginjal (
LFG) yang telah terjadi > 3
bulan dengan implikasi
pada kesehatan

13. Definisi
 Sindrom klinis pada penderita DM yang
ditandai dengan albuminuria menetap (>
300mg/24 jam ) pada minimal 2 kali
pemeriksaan dalam kurun waktu 3 sampai
6 bulan
dan/ atau
- Kerusakan glomeruler
- Penurunan LFG
ADA recommendations, Diabetes Care, January 2012

15. Mekanisme proteinuria
Site ofinjury
Glomerular hemodynamics Glomerular hyperfiltration
Afferent arteriole vasodilatation
Efferent arteriole vasoconstriction
glomerular capillary pressure
glomerular endothelial cell
Endothelial cell injury Diminished
endothelial glycocalyx
Altered VEGF signaling
Hyperglycemia< AGE, ROS Endothelial cell injury or
enzymatic cleavage
Podocyte injury or loss
GBM
Irregular thickening
Decreased negative charge
production and/or degradation of extracellular matrix
proteins
production and/or degradation of HSPG
podocyte
proximal tubule
Podocytopenia
Loss of slit diaphragm integrity
Foot process widening and
effacement
Loss negative charge
Decrease protein reabsorption
Detachment, apoptosis, lack of proliferation
Decrease or changes in subcellular localization of nephrin
Disrupted actin cytoskeleton
Loss of slit diaphragm integrity
Impaired podocyte GBM interaction
Podocalyxin
Tubular injury and interstitial fibrosis
AGE, advanced glycosylation end products; HSPG, heparan sulfate proteoglycan; ROS, reactive oxygen species; VEGF,
vascular endothelial growth factor.

18. Faktor Risiko
 Riwayat keluarga menderita DM
 Hipertensi
 Hiperglikemia tidak terkontrol
 Dislipidemia
 Obestas
 Laki-laki
 Perokok

19. Diagnosis
 Diabetes + Penurunan fungsi ginjal
dan :
1. Makroalbuminuria ATAU
2. Mikroalbuminuria (+) Retinopati,
menderita DM-tipe 1 selama 10
tahun atau lebih
KDOQI, 2007

20.  Penurunan fungsi ginjal non- ND
1. Tidak ditemukan retinopati
2. Penurunan LFG yang progresif
3. Proteinuria progresif
4. Hipertensi refrakter
5. Sedimen-sedimen urin
6. Gejala penyakit sistemik lainnya (
SLE, dll)
7. Penurunan LFG >30% dalam 2-3
bulan setelah pemberian obat
hipertensi golongan ACE-i atau ARB

21. SCREENING FOR NEPHROPATHY
WHEN: Type 1 - annually after puberty and 5 years of DM
Type 2 - at diagnosis and then annually
WHAT: random urine ACR;
and random urine dipstick
Normal
< 2.0 mg/mmol men
< 2.8 mg/mmol women
Rescreen in 1 year
Microalbuminuria
2.0 - 20 mg/mmol men
2.8 - 28 mg/mmolwomen
Macroalbuminuria
> 20 mg/mmol men
> 28 mg/mmol women
Diabetic nephropathy
diagnosed
Up to 2 repeat random urineACRs
performed 1 week to 2 months
apart
Suspicion of
nondiabetic
renal disease?
Yes
Workup or referralfor
nondiabetic renal
disease
No
Check ACR results
Only 1 abnormal ACR:
Repeat screen in 1year
Any 2 abnormal out of 3
ACRs: Diabetic
nephropathy diagnosed
1/26/2014 21

22. Recommendations for the Comprehensive
Management
of T2DM Patients with CKD
Factor Recommendations
Lifestyle factors diet, exercise, smoking,and alcohol intake
Blood glucose Treatment goal:
HbA1c <6.5%
Preprandial plasma glucose 90-130 mg/dl
Postprandial plasma glucose <180 mg/dl
Blood pressure Goal ≤130/80 mm Hg
Use maximal tolerated dose of ACE inhibitor or ARB before
adding a second agent
Cholesterol Goal <4.0 mmol/L for total cholesterol and <2.0 mmol/L for
LDL-C
Consider use of a statin irrespective of baseline lipid values for
the secondary prevention of cardiovascular disease
Platelets Consider use of low dose aspirin for the secondary prevention
of cardiovascular disease
Monitoring Annual monitoring of eGFR and ACR

23. Take Home Message
 Nefropati diabetik adalah komplikasi
jangka panjang dari DM
 Karakteristik : proteinuria, penurunan
LFG dan hipertensi
 Skrining dan intervensi dini dapat
mencegah atau memperlambat
perburukan fungsi ginjal