Diabetic Nephropathy

Kidney disease in diabetes as we all knows ‘diabetic nephropathy’ is a major microvascular complication occurring in around 20-40 % diabetic patients with prolonged diabetes. It’s a leading cause of end stage renal disease, dialysis and transplant.

Diabetic nephropathy is characterised by persistent proteinuria of >500mg/day with concomitant diabetic retinopathy, hypertension and absence of other kidney or renal tract disease.



Years of diabetes
GFR-Glomerular filtration rate
ESRD-End Stage Renal Disease




Symptoms:-

* Ankle and leg swelling. (Pedal oedema) and/ facial puffiness.
* Reduced urination (<400ml/day-oliguria). * Episodes of hypoglycaemia.
* Less requirement of insulin or antidiabetic medication.
* Reduced appetite (anorexia) and weakness.
* Nausea and vomiting.
* Itching.
* Breathlessness.
* Palpitation.

Diagnosis of diabetic nephropathy
Evidence of diabetic retinopathy ( retina changes in diabetes)
Presence of proteins in urine- presence of urine microalbumin or urine spot protein creatinine ratio of >0.2.
High levels of blood urea and creatinine
Enlarged renal size on ultrasonography.
Associated findings of- high blood pressure, anaemia and increased serum potassium levels.

What to eat?

Patient should take low sodium and protein diet. Recommended dietary protein intake is 0.6 to 0.8 gm/kg body weight/day and salt of 2 to 3 gm/day.

Lifestyle modification

Patient is required to exercise daily and loss weight to maintain ideal body weight. To avoid tobacco and alcohol.

Medications supposed to be avoided in renal diseases.

Avoid nephrotoxic drugs like NSAIDS, aminoglycosides etc, over the counter medications (medicines brought directly from the pharmacy without prescription), alternate and native medication and painkillers unless very necessary, use nephrosafe painkillers like paracetamol and tramadol. Avoid intravenous contrast agents for imaging like CT scan and angiography. Avoid metformin in renal diseases, insulin is the best choice.

Management
Good glycaemic control of HbA1c<7% Good Blood pressure control of <130/80mm hg with ACE inhibitors/ARB (angiotensin receptor blocker) as first line followed by beta blockers and calcium channel blockers. Lipids levels to remain under control

Can we cure diabetic nephropathy?
Once onset complete reversibility is not possible but we can slow the progression of diabetic nephropathy and delay onset of end stage renal disease with good glycaemia and blood pressure control and use of ACE inhibitors/ARB in early stages.

Pregnancy and diabetic nephropathy?
ACE inhibitors/ARB should be avoided as they cause foetal malformations. Best is to maintain a strict glycaemic control of HbA1C <7.0% and blood pressure control of <130/80mm of hg. Benefits of early diagnosis of kidney disease.

Kidney being an innocent organ, in diabetes, it’s prone to microvascular insult. Any further damage due to infections drugs, etc can further compromise the renal function, recovery from which may not be possible through conservative means.

Hence early diagnosed kidney diseases can have a better and prolonged survival if certain precautions are attained at the beginning itself, for example, avoiding use of painkillers, alternate medicines, intravenous contrast agents during imaging studies and nephrotoxic drugs. Taking plenty of fluids and consulting your physician each time you need to take medicines. Regular checkup for renal functions and urine for proteinuria.

Consult your physician if you have, reduced urine, burning micturition, swelling in feet, loin pain, any urinary discoloration.

Nephrology evaluation is must for patients having skin or joint problems (ex- SLE, psoriasis, leprosy, etc), cyst or stones in kidney, family history of renal diseases and patients with prolonged pain killer intake.