Diabetic nephropathy
The content of the article:
- Causes and risk factors
- Forms of the disease
- Symptoms
- Diagnostics
- Treatment
- Possible complications and consequences
- Forecast
- Prevention
Diabetic nephropathy is kidney damage that is common in patients with diabetes. The basis of the disease is damage to the renal vessels and, as a consequence, developing functional organ failure.
Diabetic nephropathy - kidney damage in patients with diabetes mellitus
Approximately half of patients with type 1 or type 2 diabetes mellitus with more than 15 years of experience develop clinical or laboratory signs of kidney damage associated with a significant decrease in survival.
According to the data presented in the State Register of Patients with Diabetes Mellitus, the prevalence of diabetic nephropathy among persons with non-insulin dependent type is only 8% (in European countries, this indicator is at the level of 40%). Nevertheless, as a result of several extensive studies, it was revealed that in some regions of Russia the incidence of diabetic nephropathy is up to 8 times higher than the declared one.
Diabetic nephropathy is a late complication of diabetes mellitus, but recently the importance of this pathology in developed countries has been increasing due to an increase in life expectancy.
Up to 50% of all patients receiving renal replacement therapy (consisting of hemodialysis, peritoneal dialysis, kidney transplantation) are patients with diabetic nephropathy.
Causes and risk factors
The main cause of renal vascular damage is high plasma glucose levels. Due to the failure of the utilization mechanisms, excess amounts of glucose are deposited in the vascular wall, causing pathological changes:
- the formation in the fine structures of the kidney of the products of the final metabolism of glucose, which, accumulating in the cells of the endothelium (the inner layer of the vessel), provoke its local edema and restructuring;
- a progressive increase in blood pressure in the smallest elements of the kidney - nephrons (glomerular hypertension);
- activation of the renin-angiotensin system (RAS), which plays one of the key roles in the regulation of systemic blood pressure;
- massive albumin or proteinuria;
- dysfunction of podocytes (cells that filter substances in the renal corpuscles).
The development of diabetic nephropathy is largely facilitated by prolonged hyperglycemia
Risk factors for diabetic nephropathy:
- unsatisfactory self-control of glycemic levels;
- early formation of insulin-dependent type of diabetes mellitus;
- a stable increase in blood pressure (arterial hypertension);
- hypercholesterolemia;
- smoking (the maximum risk of developing pathology is when smoking 30 or more cigarettes per day);
- anemia;
- burdened family history;
- male gender.
Forms of the disease
Diabetic nephropathy can take the form of several diseases:
- diabetic glomerulosclerosis;
- chronic glomerulonephritis;
- nephritis;
- atherosclerotic stenosis of the renal arteries;
- tubulointerstitial fibrosis; and etc.
In accordance with morphological changes, the following stages of kidney damage (classes) are distinguished:
- class I - single changes in the vessels of the kidney, detected during electron microscopy;
- class IIa - soft expansion (less than 25% of the volume) of the mesangial matrix (a set of connective tissue structures located between the capillaries of the vascular glomerulus of the kidney);
- class IIb - severe mesangial expansion (more than 25% of the volume);
- class III - nodular glomerulosclerosis;
- class IV - atherosclerotic changes in more than 50% of the renal glomeruli.
The sequence of development of pathological phenomena in diabetic nephropathy
There are several stages of nephropathy progression based on a combination of many characteristics.
1. Stage A1, preclinical (structural changes not accompanied by specific symptoms), average duration - from 2 to 5 years:
- the volume of the mesangial matrix is normal or slightly increased;
- the basement membrane is thickened;
- the size of the glomeruli is not changed;
- there are no signs of glomerulosclerosis;
- slight albuminuria (up to 29 mg / day);
- proteinuria is not noted;
- the glomerular filtration rate is normal or increased.
2. Stage A2 (initial decline in renal function), duration up to 13 years:
- there is an increase in the volume of the mesangial matrix and the thickness of the basement membrane of varying degrees;
- albuminuria reaches 30–300 mg / day;
- the glomerular filtration rate is normal or slightly reduced;
- proteinuria is absent.
3. Stage A3 (progressive decline in renal function), usually develops 15-20 years after the onset of the disease and is characterized by the following:
- a significant increase in the volume of the mesenchymal matrix;
- hypertrophy of the basement membrane and glomeruli of the kidney;
- intense glomerulosclerosis;
- proteinuria.
In addition to the above, the classification of diabetic nephropathy, approved by the Ministry of Health of the Russian Federation in 2000, is used:
- diabetic nephropathy, stage of microalbuminuria;
- diabetic nephropathy, stage of proteinuria with preserved nitrogen excretory function of the kidneys;
- diabetic nephropathy, stage of chronic renal failure.
Symptoms
The clinical picture of diabetic nephropathy at the initial stage is nonspecific:
- general weakness;
- increased fatigue, decreased performance;
- decreased exercise tolerance;
- headache, episodes of dizziness;
- feeling of a "stale" head.
At the initial stage of diabetic nephropathy, the patient feels pain and general weakness
As the disease progresses, the spectrum of painful manifestations expands:
- dull pain in the lumbar region;
- swelling (more often on the face, in the morning);
- violations of urination (increased frequency during the day or at night, sometimes accompanied by pain);
- decreased appetite, nausea;
- thirst;
- daytime sleepiness;
- cramps (more often the calf muscles), musculoskeletal pain, pathological fractures are possible;
- increased blood pressure (as the disease evolves, hypertension becomes malignant, uncontrollable).
With the progression of diabetic nephropathy, lower back pain, swelling, drowsiness, thirst occur
In the later stages of the disease, chronic kidney disease develops (the early name is chronic renal failure), characterized by a significant change in the functioning of organs and disability of the patient: an increase in azotemia due to the failure of the excretory function, a shift in acid-base balance with acidification of the internal environment of the body, anemia, electrolyte disturbances.
Diagnostics
Diagnosis of diabetic nephropathy is based on laboratory and instrumental research data if the patient has type 1 or type 2 diabetes mellitus:
- general urine analysis;
- monitoring albuminuria, proteinuria (annually, detection of albuminuria more than 30 mg per day requires confirmation in at least 2 consecutive tests out of 3);
- determination of the glomerular filtration rate (GFR) (at least once a year in patients with stages I – II and at least 1 time in 3 months in the presence of persistent proteinuria);
- studies for creatinine and serum urea;
- blood lipid analysis;
- self-monitoring of blood pressure, daily blood pressure monitoring;
- Ultrasound examination of the kidneys.
Diagnosis of diabetic nephropathy includes kidney ultrasound
Treatment
The main groups of drugs (as preferred, from drugs of choice to drugs of the last stage):
- angiotensin-converting (angiotensin-converting) enzyme (ACE inhibitors) inhibitors;
- angiotensin receptor blockers (ARA or ARB);
- thiazide or loop diuretics;
- slow calcium channel blockers;
- α- and β-blockers;
- centrally acting drugs.
In addition, the recommended intake of lipid-lowering drugs (statins), antiplatelet agents and diet therapy.
Renal replacement therapy for diabetic nephropathy is used when conservative treatment is ineffective
In case of ineffectiveness of conservative methods of treatment of diabetic nephropathy, the feasibility of renal replacement therapy is assessed. In the presence of the prospect of kidney transplantation, hemodialysis or peritoneal dialysis is considered as a temporary stage in preparation for the surgical replacement of a functionally incompetent organ.
Possible complications and consequences
Diabetic nephropathy leads to the development of severe complications:
- chronic kidney failure (chronic kidney disease);
- to heart failure;
- to coma, death.
Forecast
With complex pharmacotherapy, the prognosis is relatively favorable: reaching the target blood pressure level of no more than 130/80 mm Hg. Art. in combination with strict control of glucose levels leads to a decrease in the number of nephropathies by more than 33%, cardiovascular mortality by 1/4, and mortality from all cases by 18%.
Prevention
Preventive measures are as follows:
- Systematic control and self-control of glycemic levels.
- Systematic control of the level of microalbuminuria, proteinuria, creatinine and blood urea, cholesterol, determination of the glomerular filtration rate (the frequency of controls is determined depending on the stage of the disease).
- Preventive examinations of a nephrologist, neurologist, ophthalmologist.
- Compliance with medical recommendations, taking drugs in the indicated doses according to the prescribed regimens.
- Quitting smoking, alcohol abuse.
- Lifestyle modification (diet, dosed exercise).
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Olesya Smolnyakova Therapy, clinical pharmacology and pharmacotherapy About the author
Education: higher, 2004 (GOU VPO "Kursk State Medical University"), specialty "General Medicine", qualification "Doctor". 2008-2012 - Postgraduate student of the Department of Clinical Pharmacology, KSMU, Candidate of Medical Sciences (2013, specialty "Pharmacology, Clinical Pharmacology"). 2014-2015 - professional retraining, specialty "Management in education", FSBEI HPE "KSU".
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
