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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Evidence of diabetes mellitus, typically over 10 years.

  • Albuminuria usually precedes decline in GFR.

  • Other end-organ damage, such as retinopathy, is common.

GENERAL CONSIDERATIONS

Diabetic kidney disease is the most common cause of ESKD in the United States. The incidence of CKD is approximately 30% in both type 1 and type 2 diabetes mellitus. ESKD is much more likely to develop in persons with type 1 diabetes mellitus, in part due to fewer comorbidities and deaths before ESKD ensues. With the current epidemic of obesity and type 2 diabetes mellitus, rates of diabetic nephropathy will continue to increase. Those with a family history of kidney disease are at higher risk. Mortality rates are higher for patients with diabetes who also present with kidney disease compared to those without CKD.

CLINICAL FINDINGS

Kidney disease develops about 10 years after the onset of diabetes mellitus. It may be present at the time type 2 diabetes mellitus is diagnosed. The first stage is hyperfiltration with an increase in GFR, followed by the development of moderate albuminuria (30–300 mg/day). With progression, albuminuria increases to severe (greater than 300 mg/day) and can be detected on urine dipstick as overt proteinuria; GFR subsequently declines over time. Yearly screening for moderate albuminuria is recommended for all patients with diabetes to detect disease at its earliest stage, though diabetic kidney disease less commonly can present as nonproteinuric CKD.

The most common lesion in diabetic kidney disease is diffuse glomerulosclerosis, but nodular glomerulosclerosis (Kimmelstiel-Wilson nodules) is pathognomonic (eFigure 24–18). The kidneys are usually enlarged until disease becomes advanced. Kidney biopsy is not required in most patients unless atypical findings are present, such as sudden onset of proteinuria, nephritic features (see above), massive proteinuria (greater than 10 g/day), urinary cellular casts, or rapid decline in GFR.

eFigure 24–18.

Diabetic nephropathy. There is diffuse and nodular expansion of mesangial matrix, mesangiolysis, and adjacent capillary microaneurysm formation (Periodic acid–Schiff 200×). (Used with permission from Nicole Andeen, MD.)

Patients with diabetes are prone to other kidney diseases. These include papillary necrosis, chronic interstitial nephritis, and type 4 (hyporeninemic hypoaldosteronemic) renal tubular acidosis. Patients are more susceptible to AKI from many insults, including intravenous contrast material and concomitant use of an ACE inhibitor or ARB with NSAID.

TREATMENT

At the onset of moderate albuminuria, treatment is necessary. Strict glycemic control should be emphasized early in diabetic nephropathy, with recognition of risk of hypoglycemia as CKD becomes advanced (see CKD section). Recommended blood pressure goals should be tailored to the individual patient. In the ACCORD trial, lowering blood pressure below 140/90 mm Hg did not confer survival benefit in those with moderate albuminuria (30–300 mg/day) and ...

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