Diabetic Nephropathy: A Comprehensive Review for Health ......Citation: Chowdhury SR, Tanzil T,...

International Journal of Diabetes and Endocrinology

Diabetic Nephropathy: A Comprehensive Review for Health Care Professionals

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Sumon Rahman Chowdhury*1, Tasnuva Tanzil2, Rezaul Haider Chowdhury3, Alam Mohammad Sharif 4

1Senior Medical Officer, Department of Diabetes, Endocrinology and Metabolism, Chittagong Diabetic General Hospital, Chittagong 2Assistant Registrar, Department of Anaesthesia and Intensive Care Unit, Chattogram Medical College Hospital 3Consultant Internist, Department of Internal Medicine, Chittagong Diabetic General Hospital 4Consultant, Department of Physical Medicine, Chittagong Diabetic General Hospital

Corresponding author: Sumon Rahman Chowdhury, Senior Medical Officer, Department of Diabetes, Endocrinology and Metabolism, Chittagong Diabetic General Hospital, Chittagong. Tel: 01670393031; E-mail: [email protected]

Citation: Chowdhury SR, Tanzil T, Chowdhury RH, Sharif AM (2020) Diabetic Nephropathy: A Comprehensive Review for Health Care Professionals. Int Jou Diab&Endocrinol: IJDE-108. DOI: 10.46715/ijde2020.11.1000108

Received Date: 12 November, 2020; Accepted Date: 16 November, 2020; Published Date: 23 November, 2020

Keywords: Diabetic Nephropathy, Diabetes, Health Care Professionals

Introduction

Diabetic Nephropathy (DN) is the leading cause of ESRD in the UK. In 2012, DN accounted for 26% of cases ESRD [1], and 40% diabetics will develop DN [2].

The features of DN are increasing urinary albumin excretion, rising BP and declining renal function [3]. There are specific pathological changes with five different stages. The key is the level of urinary albumin excretion-microalbuminuria (incipient nephropathy) or macroalbuminuria/proteinuria (overt nephropathy) [4]. As it is an asymptomatic process screening is required [2, 3].

Normal Microalbuminuria Macroalbuminuria

ACR- Albumin/Creatinine

Ratio (mg/mmol)


In T1DM microalbuminuria usually appears after 5-15 years post diagnosis, with proteinuria/ macroalbuminuria found in 15-40% [2, 5]. Not all will have increasing UAE in T1DM a third will revert to normal [7].

Risk factors include duration of DM, hyperglycaemia, hypertension, ethnicity and genetic factors. The UKPDS and DCCT showed that improved glycaemia reduced progression

[4, 8, 9], and in T2DM, controlling hypertension reduces risk

[4]. Suppression of RAS is the key to risk reduction [2, 3, 10].

There is increased cardiovascular risk [2, 3]. Compared to normal UAE, microalbuminuria increases CVD risk by 2-3 times. With proteinuria this risk is increased by 103.

Diabetic nephropathy can be easily screened for and the modification of risk factors can improve the outcome. We will discuss the risk factors, pathogenesis, staging and treatment of this important cause of mortality and morbidity.

Search Strategy

Available studies and abstracts were identified through Pub Med and Medline data bases (From 1998-2019) and Cochrane data bases. Key search terms were diabetes and nephropathy. All available studies and abstracts describing the relationship between diabetes and nephropathy were included. The reference list of review articles was also searched.

Discussion

Epidemiology

Approximately 463 million people worldwide have diabetes and the prevalence is expected to rise to 700 million in the next 20 years [11]. This growing epidemic carries with it an increasing burden of micro and macrovascular complications. Diabetic nephropathy is one of the serious microvascular complications of diabetes [12].

Diabetic nephropathy is defined as eGFR of 30 mg/g. It occurs in up to 40% of all patients with diabetes [13] and accounts for >44% of ESRD patients [14]. The prevalence of DN has doubled over the past decade, especially in areas of high prevalence of diabetes like USA, Japan and Europe. About 50% of DN patients will progress to ESRD within 10 years of diagnosis, increasing to 75% in 20 years if no preventive measures are implemented [13].

Diabetic nephropathy contributes significantly to the economic burden of diabetes. In UK, the cost of diabetic complications in

2011/2012 was estimated at £14 billion, by 2035/2036 this is expected to rise to £22 billion. Worldwide, healthcare costs for diabetic patients are much higher than non- diabetic patients. Also, among diabetic patients the cost of health care is much higher in those with complications (Micro < Macro

Figure 6: Postsurgical photograpgh showing wide excision of

mass located in retromolar área.

Discussion

These type of tumours are very rare they comprise only 5% of

neoplasms and are seen in 0.4-2.6 for every 100,000 cases around

the world, the mucoepidermoid tumour affects parotid and minor

salivary glans in adults and is mostly seen in women and Young

adults, most tof the cases arise in the the parotid gland with this

ccase accounting for only 2-4% of the cases because it was seen in

the submandibular gland, this patient is currently under treatment

he was performed two sugeries for removal of ganglions locanated

in neck and in the submandbullary gland, highes prevalence for this

type of tumour is around the fifth decade of life and they can be

asymptomatic like in this case with the patient having few to no

symptoms. It has a puripotent cell origin and as we mention can

be classidief into three stages [3].

References


Figure1: Metabolic and Haemodynamic factors contributing to diabetic nephropathy

Risk factors for diabetic nephropathy

Risk factors for diabetic nephropathy include positive family history, hyperglycemia, hypertension, smoking and others.

Genetics and ethnicity

There is a concordance of nephropathy among twins having T1DM [17]. There is five times more chance to develop nephropathy in

diabetic siblings of patient with diabetes and nephropathy [18].

Beneficial effects of ACE inhibition on nephropathy showed there are high levels of ACE in patients with nephropathy and diabetes,

especially abnormal alleles of ACE gene carriers [19].

ESRD is more common in ethnic groups like African Americans, Mexican Americans and Native Americans [20].

Hyperglycemia

Hyperglycemia and duration of diabetes is a strong risk factor of diabetic nephropathy [19]. In DCCT and other treatment trials showed lowering glucose levels reduces DN [23]. Diabetic nephropathy is not common in patients with HbA1c

Figure 6: Postsurgical photograpgh showing wide excision of

mass located in retromolar área.

Discussion

These type of tumours are very rare they comprise only 5% of

neoplasms and are seen in 0.4-2.6 for every 100,000 cases around

the world, the mucoepidermoid tumour affects parotid and minor

salivary glans in adults and is mostly seen in women and Young

adults, most tof the cases arise in the the parotid gland with this

ccase accounting for only 2-4% of the cases because it was seen in

the submandibular gland, this patient is currently under treatment

he was performed two sugeries for removal of ganglions locanated

in neck and in the submandbullary gland, highes prevalence for this

type of tumour is around the fifth decade of life and they can be

asymptomatic like in this case with the patient having few to no

symptoms. It has a puripotent cell origin and as we mention can

be classidief into three stages [3].

References


Microalbuminuria/ a predictor of clinical complications

Urine albumin ranging from 30 to 300mg in a 24-h urine sample is defined as Microalbuminuria [34, 36, 39].

Microalbuminuria (MA) and clinical complications

T1DM: It is an independent predictor of CV risks in patients above the age of 45 years [35].

T2DM: It is considered to be the harbinger and strongly associated with CV risks and mortality and morbidity [35].

Part of metabolic syndrome is also manifested by the levels of microalbuminuria in association with other components (metabolic

like lipids and BP, urate, body habitus and hs-CRP).

Association with SBP and CRP in causing endothelial dysfunction [35, 37]

Elevated SBP is associated with generalized endothelial dysfunction and leaky capillaries are associated with albumin

leak in the glomerulus and chronically inflamed endothelium.

Insulin Resistance

Central Obesity

Low levels of HDL Cholesterol

High Triglyceride levels

Systolic Hypertension

Lack of time dip in 24hr BP monitoring

Salt Sensitivity

Endothelial Dysfunction

Hypercoagulability

Impaired Fibrinolysis

Renal Dysfunction

Table 2: Showing the constellation of findings associated with microalbuminuria [35]

Study Title

Number

of Subjects

Study Population

Mean Follow-up

Intervention

Renal outcomes seen with albuminuria to

RAAS blockade IDNT

1,715

Type 2 Diabetes,

hypertension

4 years

Irbesartan,

Amlodipine or Placebo

50% reduction in

proteinuria in the first year;

decrease in renal risk

RENAAL

1,513

Type 2 Diabetes

3.4 years

Losartan (50 mg or 100 mg) or

placebo

50% reduction in

albuminuria in the first six months: decreased risk for ESRD by 45%

MARVAL

332

Type 2 Diabetes

6 months

Valsartan vs Amlodipine

Urinary AER at 24 weeks was reduced more with

Valsartan

Table 3: Depicting the clinical trials of Albuminuria and renal outcomes in T2DM [38]

Int Jou Diab&Endocrinol: IJDE-108 3



Study Title and design with interventions Gist of outcomes

Life study, Losartan studied in interventions Microalbuminuria is associated with hypertension and CV

risks

TOMS, Treatment of mild HT study, Enalapril Reduction in microalbuminuria along with BP control

PREVEND (Prevention of vascular and renal

end-stage disease)

Increase e-GFR with Microalbuminuria dure

to hyperfiltration and reduced GFR with macroalbuminuria

HOPE Increased CV risk and events with Microalbuminuria

Framingham Study Increased morbidity and mortality due to CV disease

Copenhagen City Heart Study Microalbuminuria associated with increased lipids and raised

BP with increased mortality

Table 4: Showing other studies related to microalbuminuria and CV risk not totally related to diabetes [38, 39]

Framingham Heart Study, HOPE, LIFE, PREVEND, HARVEST, HOOM, MONICA and Copenhagen city heart study emphasized the importance of control of BP and Microalbuminuria (some using RAAS blockade) in reducing the incidence of CV events and associated morbidity and mortality.

Microalbuminuria can be useful screening method in assessing CV risk in [35]

1) T2DM patients 2) >45 years older T1DM 3) Stage 2 Hypertension in elderly

Macroalbuminuria/a predictor of clinical complications

Macroalbuminuria predicts retinopathy, neuropathy and cardiovascular disease.

Gall M et al, in their study showed 13.5% of T2DM had macroalbuminuria. Arterial hypertension was prevalent in 85% and ulcer of foot was seen in 25% [40].

Susan S et al, in a cross-sectional study involving 947 T2DM patients from year 1990 to 1993. DN was prevalent in 75% among macroalbuminuric patients. Among the patients who were suffering from DN, proliferative retinopathy was detected in 49%. The prevalence of neuropathy was also higher, 68% of patients with macroalbuminuria was having neuropathy. Cardiovascular disease was highly prevalent among those with macroalbuminuria, in 58% of the patients. The study showed an independent association between macroalbuminuria and occurrence of cardiovascular disease [41].

Diabetic nephropathy stages

First stage; Early, hyperfunction [42]

Characterized by hyperfunction

Structural changes; hyperplasia and hypertrophy of nephrons, kidney size increased

GFR increased 20-40%

Blood pressure within normal

Albumin excretion is increased, and by physical activity (provocation test) increased This stage is reversible by blood sugar control (such as insulin treatment)

Second stage; Glomerular lesion without clinical finding [42]

It develops over years. Structural changes; increased thickness of basement membrane GFR increased 20-30% or normal Blood pressure within normal Albumin excretion most of patients are within normal and exercise test abnormal after years This stage is reversible by blood sugar control.


6


Third Stage; Incipient stage [42]

Structural changes not well studied. GFR still increased Blood pressure increased Albumin excretion increased 25ug/min each year

Fourth stage; Overt diabetic nephropathy [42]

Characterized by pronounced proteinuria Structural changes; diffuse and nodular glomerulosclerosis and hyalinosis of arteriolar GFR decreased Albumin excretion /progressive macroproteinuria Blood pressure increased The antihypertensive treatment retards the progression, aim of BP (140/85-90).

Fifth stage; End stage renal failure [42]

Characterized by glomerular closure GFR or = 90ml/min

Stage 2 GFR 98-60ml/min



Stage 5 GFR

Alternatives to UAE

Semi-quantitative dipstick measure of Micral Test II

albuminuria

Qualitative dipstick test for proteinuria Combur M, Boehringer Manheim.

Quantitative measurement of protein in urine >430mg/l - 100% sensitivity and 93%

spot sample specificity

24 urine protein collection >500mg/24h-confirms diagnosis of

proteinuria

Table 7: Alternatives to UAE [50]

Prevent nephropathy; optimal glycaemic control, life style, blood pressure and lipids control

Early management of hyperglycemia, hypertension, dyslipidemia and smoking in diabetic patients, is very important to prevent or delay the progression of DN [51].

Lifestyle measures include salt restriction, to stop smoking, exercise and maintaining an ideal weight [52].

Improvement of glycemic control slows the progression and the onset of microalbuminuria in both T1DM and T2DM. The HbA1c target should be < 6.5 % and the greatest benefit comes from early and better control [52].

Uncontrolled BP leads to progression of proteinuria and deterioration of renal function. The recommended target BP is below 130/80 according to NICE guidelines in both T1DM and T2DM. ACEIs or ARBs are the first drugs of choice and both can slow the progression of DN [52].

Target LDL-C < 100 mg/dl and < 70 mg/dl in diabetic patient and diabetic with CVD respectively. Collaborative Atorvastatin Diabetes Study (CARDS) revealed a great reduction of CVD and suggested that all DM patients should be on statins [51].

Management of microalbuminuria [53]

Management of microalbuminuria involves intensive glycaemic control which reduces the progression of the UAE in both T1DM &T2DM patients.

Blood pressure control reduces the progression and development of the albuminuria. Treatment with ACEI or ARB’s play a role by reducing the intraglomerular pressure and decreases the hyperfiltration, delays deterioration of the eGFR along with reduction of the BP. Doses are increased to maximum tolerated and approved dose with continuous monitoring of the creatinine and potassium level. Monitoring for UAE to assess treatment response and disease progression is required.

Other classes of antihypertensive therapy such as the Ca channel blockers, beta blockers and diuretics are used along with ACEI or ARBs for BP control.

Protein diet restriction delays the progression of albuminuria and delays the deterioration of eGFR.

Management of macroalbuminuria [53]

Management of macroscopic albuminuria involves optimization of glucose control, blood pressure, lipids and maintenance of ideal

body weight through therapeutic life style modification/ reinforcement together with drug adjustment if needed, to achieve

required target. Vaccination for HBV should be anticipated.

Monitoring for eGFR every 6 month for deterioration and complications of Chronic kidney disease complications when eGFR<

60ml/min/1.73m2; Hb, Urea, creatinine, potassium level, HCO3-, Ca2+, PO2-, se albumin, and at least yearly parathyroid hormone

level, vit D level.

Adjustment for drug dose is required to achieve; target glycaemia, blood pressure, lipid control, smoking cessation therapy when

indicated and avoidance of hypotension.

Counseling regarding diet: Advise salt restriction (


Avoid medications that may deteriorate renal function or stopping medications that are contraindicated according to the stage of renal failure.

Management of different stages of diabetic nephropathy/

Nephrologist referral

There should be a multidisciplinary approach to managing patients with diabetic nephropathy, focusing not only on slowing progression but also on modifying cardiovascular risk factors [52]. DCCT trial showed that intensive management of diabetes could delay microalbuminuria and slow the progression of microalbuminuria to proteinuria [54].

Stage 1; No proteinuria

Lifestyle Modification Dietary control of CHO and fats and salt restriction. Exercise and stop smoking Glycemic Control: Target HbA1c 1 g/24hr) are indications for referral

[62].

Prognosis of Diabetic nephropathy

Diabetic nephropathy (DN) causes considerable morbidity and mortality. In the US and Europe, DN is the major cause of end-stage renal disease (ESRD) [63]. Both T1DM and T2DM develop ESRD, but larger proportions affected are those with T2DM, due to the increase in prevalence of T2DM. In T1DM with nephropathy, ESRD accounts for 59-66% of mortality. The

growing prevalence of ESRD in Europe seen in type 1 diabetics with proteinuria is 50%, while in Type 2 diabetics it is 3-11%, in a period of 10years following the start of proteinuria. The prediction of morbidity and mortality in DN is by Proteinuria. The mortality rate was small and constant in those diabetics who had no proteinuria while those diabetics with proteinuria had 40 times increase in death rate. In a study done in Germany, the chances of surviving for 5 years, in older type 2 diabetics was below 10%, and around 40% in young type1 diabetics [64, 65].

The prognosis of DN in both T1DM and T2DM has been improving due to the targeted approach, timely recognition of DN and managed appropriately according to the stage.

Conclusion

Diabetic nephropathy is one of the commonest microvascular complications of diabetes and is associated with other diabetes related microvascular diseases. It affects 20-40% of people with diabetes and is a leading cause of ESRD53. Interplay of multiple environmental and genetic factors determines its development and progression, the most important of these is uncontrolled hyperglycaemia and hypertension. The hallmark of DN is the presence of microalbuminuria in the early stages which progresses over a variable period to macroalbuminuria and deterioration of the renal function to ESRD requiring RRT.

Adequate control of blood glucose and hypertension are the mainstay of management in addition to life style interventions similar to those required to manage renal failure due to causes

[52].

Competing interests

The authors declared no competing interests regarding the publication of the paper.

Authors Contribution

Sumon Rahman Chowdhury contributed to the study conception and design, supervised the study, conducted data analysis and wrote the manuscript. Reza Haider Chy and Tasnuva Tanzil planned the study and prepared the first draft proposal. Alam Md. Sharif contributed to the data analysis, supervised the study and critically revised the manuscript.

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