Diabetic nephropathy

Diabetic nephropathy (nephropatia diabetica), also

known as KimmelstielWilson syndrome, or nodular diabetic glomerulosclerosis[1] and intercapillary
glomerulonephritis, is a progressive kidney disease
caused by angiopathy of capillaries in the kidney
glomeruli. It is characterized by nephrotic syndrome
and diuse glomerulosclerosis. It is due to longstanding
diabetes mellitus, and is a prime indication for dialysis in
many developed countries. It is classied as a small blood
vessel complication of diabetes.[2]

glucose is poorly controlled. Serum creatinine and BUN

may increase as kidney damage progresses.

The word diabetes means passing through, referring to

the polyuria (abnormal increase of urine production), a
symptom historically present in those aected by the disease. When the level of blood glucose rises beyond the
kidneys capacity to reabsorb glucose from the renal ultraltrate, glucose remains diluted in the uid, raising its
osmotic pressure and causing more water to be carried
out, thus, increasing the excreted urine volume. The increased volume dilutes the sodium chloride in the urine,
signalling the macula densa to release more renin, causing vasoconstriction, a survival mechanism to retain water by passing less blood through the kidneys. Because
the kidney is nurtured exclusively by the blood it lters,
the vasoconstriction also reduces the nutrients supplied
to it, causing infarct of its tissues and reduction of renal
function.

A kidney biopsy conrms the diagnosis, although it is

not always necessary if the case is straightforward, with
a documented progression of proteinuria over time and
presence of diabetic retinopathy on examination of the
retina of the eyes.

2 Cause

Signs and symptoms

Kidney failure provoked by glomerulosclerosis leads

to uid ltration decits and other disorders of kidney function. There is an increase in blood pressure
(hypertension) and uid retention in the body plus a reduced plasma oncotic pressure causing edema. Other
complications may be arteriosclerosis of the renal artery
and proteinuria.
Throughout its early course, diabetic nephropathy has no
symptoms. They develop in late stages and may be a result
of excretion of high amounts of protein in the urine or due
to renal failure:
edema: swelling, usually around the eyes in the
mornings; later, general body swelling may result,
such as swelling of the legs

3 Pathophysiology

foamy appearance or excessive frothing of the urine

(caused by the proteinuria)
unintentional weight gain (from uid accumulation)
anorexia (poor appetite)
nausea and vomiting
malaise (general ill feeling)
fatigue
headache
frequent hiccups

The rst laboratory abnormality is a positive microalbuminuria test. Most often, the diagnosis is suspected when
a routine urinalysis of a person with diabetes shows too Illustration depicting diabetic nephropathy
much protein in the urine (proteinuria). The urinalysis
may also show glucose in the urine, especially if blood Glomerular hyperltration is the basic pathophysiology
1

2
in diabetic nephropathy. This leads to intraglomerular hypertension. ACE inhibitor drugs help prevent diabetic nephropathy by preventing this step. Progression from glomerular hyperlteration leads to the stage
of basement membrane thickening. This is the earliest
detectable change in the course of diabetic nephropathy.
This is followed by expansion of mesangium and nally
by nodular sclerosis. At this stage, the kidney may leak
more serum albumin (plasma protein) than normal in the
urine (albuminuria), and this can be detected by sensitive medical tests for albumin. This stage is called microalbuminuria. As diabetic nephropathy progresses,
increasing numbers of glomeruli are destroyed by progressive nodular glomerulosclerosis. Consequently, urine
albumin increases to the point that it may be detected by
ordinary urinalysis techniques. At this stage, a kidney
biopsy generally clearly shows diabetic nephropathy. The
Armanni-Ebstein change or Armanni-Ebstein cells consists of deposits of glycogen in the tubular epithelial cells
(pars straight of proximal convoluted tubule and loop of
Henle). Because most diabetics are treated before this
stage, it is very rare to see it at the present time. It appears
in decompensated diabetics with glycemia higher than
500 mg/dL and in the presence of severe glycosuria; it is
a reversible alteration without functional manifestations.
The interstitium shows nonspecic chronic changes.

TREATMENT

out retinopathy gives the suspicion that the renal impairment is not caused by diabetes itself but it is the result of
comorbidity (e.g. glomerulonephritis).

5 Treatment
The goals of treatment are to slow the progression of
kidney damage and control related complications. The
main treatment, once proteinuria is established, is ACE
inhibitor drugs, which usually reduces proteinuria levels
and slows the progression of diabetic nephropathy. Several eects of the ACEIs that may contribute to renal
protection have been related to the association of rise in
Kinins which is also responsible for some of the side effects associated with ACEIs therapy such as dry cough.
The renal protection eect is related to the antihypertensive eects in normal and hypertensive patients, renal vasodilatation resulting in increased renal blood ow
and dilatation of the eerent arterioles.[4] Many studies have shown that related drugs, angiotensin receptor
blockers (ARBs), have a similar benet. However, combination therapy, according to the ONTARGET study,[5]
is known to worsen major renal outcomes, such as increasing serum creatinine and causing a greater decline
in estimated glomerular ltration rate (eGFR).

Blood-glucose levels should be closely monitored and

controlled. This may slow the progression of the dis4 Diagnosis
order, especially in the very early (microalbuminuria)
stages. Medications to manage diabetes include oral hyDiagnosis is based on the measurement of urinary poglycemic agents and insulin injections. As kidney failalbumin. We can dene:
ure progresses, less insulin is excreted, so lesser doses
may be needed to control glucose levels.
Normoalbuminuria: urinary albumin excretion <30
Diet may be modied to help control blood-sugar
mg/24h, it is the physiological state;
levels.[5] Modication of protein intake can aect
Microalbuminuria: urinary albumin excretion in the hemodynamic and nonhemodynamic injury.
range of 30299 mg/24h;
High blood pressure should be aggressively treated with
antihypertensive medications, in order to reduce the risks
Clinical (overt) albuminuria: urinary albumin excreof kidney, eye, and blood vessel damage in the body. It
tion 300 mg/24h.
is also very important to control lipid levels, maintain a
healthy weight, and engage in regular physical activity.
Diabetic patients are suggested to control albumin excrePatients with diabetic nephropathy should avoid taking
tion every year. Urinary albumin collection can also be
the following drugs:
timed (normal value <20 mg/min) or a random spot collection (normal value <30 g/mg). Abnormal values cor Contrast agents containing iodine
relate with nephropathy.
Another diagnostic tool is glomerular ltration rate es Commonly used non-steroidal anti-inammatory
teem (eGFR) based on Cockroft and Gault or on Leveys
drugs (NSAIDs) like ibuprofen and naproxen, or
(MDRD modied) formulae, both based on creatinine
COX-2 inhibitors like celecoxib, because they may
values and patients age. Normal eGFR is above 90
2
injure the weakened kidney.
mm/min/1.73 m ; dierent stages of renal damage can
be identied by eGFR intervals. Before the use of eGFR,
GFR was calculated using invasive technique such as Urinary tract and other infections are common and can
inulin (or radioactive inulin analogues) injection.
be treated with appropriate antibiotics.
Diabetic nephropathy is usually preceded by the onset of Dialysis may be necessary once end-stage renal disease
diabetic retinopathy; the evidence of nephropathy with- develops. At this stage, a kidney transplantation must be

3
considered. Another option for type 1 diabetes patients
is a combined kidney-pancreas transplant.

7 Epidemiology

C-peptide, a by-product of insulin production, may The syndrome can be seen in patients with diabetes (usuprovide new hope for patients suering from diabetic ally less than 15 years after onset) after about 5 years
in type 1 diabetes. Clinical nephropathy secondary to
nephropathy.[6]
glomerular disease usually manifests 1525 years after
In August 2014, AstraZeneca announced it had agreed
diagnosis of diabetes and aects 25-35% of patients unto collaborate with Mitsubishi Tanabe Pharma to leverder the age of 30 years. It is the leading cause of preage the pairs strengths, expertise and assets on diabetic
mature death in young diabetic patients (between 50 and
nephropathy, in a bid to develop high quality drugs much
70 years old). The disease is progressive and may cause
quicker than working alone. According to the National
death two or three years after the initial lesions, and is
Institute of Health 60% to 70% of diabetic suerers in
more frequent in men. Diabetic nephropathy is the most
the U.S. alone suered from nerve disorders related to
common cause of chronic kidney failure and end-stage
diabetic nephropathy. The three year research agreement
kidney disease in the United States. People with both
had the objective of creating new treatments to replace
type 1 and type 2 diabetes are at risk. The risk is higher if
expensive and limited options currently in place, mainly
blood-glucose levels are poorly controlled. Furthermore,
[7]
being dialysis or kidney transplantation.
once nephropathy develops, the greatest rate of progression is seen in patients with poor control of their blood
pressure. Also people with high cholesterol level in their
5.1 Compounds in Development
blood have much more risk than others.
Several compounds are in development for diabetic
kidney disease.
These include, but are not limited to, bardoxolone methyl,[8] olmesartan medoxomil,
sulodexide, NOX-E36,[9] and avosentan.[10]

Prognosis

Diabetic nephropathy continues to get gradually worse.

Complications of chronic kidney failure are more likely
to occur earlier, and progress more rapidly, when it is
caused by diabetes than other causes. Even after initiation of dialysis or after transplantation, people with diabetes tend to do worse than those without diabetes.
Possible complications include:
hypoglycemia (due to decreased renal clearance of
insulin)
rapidly progressing chronic kidney failure
end-stage kidney disease
hyperkalemia
severe hypertension
complications of hemodialysis

8 History
The syndrome was discovered by British physician Clifford Wilson (19061997) and German-born American
physician Paul Kimmelstiel (19001970) and was published for the rst time in 1936.[11]

9 See also
Diabetic diet
Hyperbaric medicine
Nephrology

10 Additional images
Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. H&E stain.
Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. Another glomerulus.
H&E stain.
Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. Another glomerulus.
H&E stain.

complications of kidney transplant

Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAS stain.

coexistence of other diabetes complications

Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAS stain.

peritonitis (if peritoneal dialysis used)

increased infections

Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAM stain.

12
Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAM stain.

11

References

[1] Berkman, James; Rifkin, Harold (1973). Unilateral nodular diabetic glomerulosclerosis (Kimmelstiel
Wilson): Report of a case. Metabolism 22 (5): 715722.
doi:10.1016/0026-0495(73)90243-6. PMID 4704716.
[2] Longo et al., Harrisons Principles of Internal Medicine,
18th ed., p.2982
[3] Burtis, C.A.; Ashwood, E.R. and Bruns, D.E. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics.
5th Edition. Elsevier Saunders. p.1560
[4] Diabetes Mellitus and Angiotensin Converting Enzyme Inhibitors
[5] The ONTARGET Investigators; Yusuf, S; Teo, KK;
Pogue, J; Dyal, L; Copland, I; Schumacher, H et
al.
(2008).
Telmisartan, Ramipril, or Both in
Patients at High Risk for Vascular Events.
New
England Journal of Medicine 358 (15): 154759.
doi:10.1056/NEJMoa0801317. PMID 18378520.
[6] Wahren J, Ekberg K, Jrnvall H (2007). C-peptide
is a bioactive peptide. Diabetologia 50 (3): 5039.
doi:10.1007/s00125-006-0559-y. PMID 17235526.
[7] AstraZeneca and MTPC come together for research on
diabetic nephropathy drugs. Genetic Engineering News.
20 August 2014. Retrieved 21 August 2014.
[8] http://www.medscape.com/viewarticle/590644
[9] Clinical trial number NCT01547897 for NOX-E36 in
Patients With Type 2 Diabetes Mellitus and Albuminuria
at ClinicalTrials.gov
[10] http://www.medicalnewstoday.com/articles/139028.php
[11] Kimmelstiel P, Wilson C (1936). Benign and malignant hypertension and nephrosclerosis. A clinical and
pathological study.. Am J Pathol 12 (1): 4548. PMC
1911030. PMID 19970253.

Berlowitz, D. R. and Weinberg, M. H. (1998). In

adequate management of blood glucose in diabetic
population. N England J. Med. 339: 1957 1963.
Burt, V. L., R. and Duston, H. P. (1995). Prevalence
of hypertension in the adult US population: Results
from the third National Health and Nutrition examination survey (1988 - 1991) 25:305 313.
Ferro, P. V. and Ham., A. B. (1957). American
journal on clinical pathology 28:208 211.
http://www.WHO.org. (2012). Therapic Review.
Patient with diabetes nephropathy-medication for
urinary tract infection.

EXTERNAL LINKS

Israli, Z. H (1992). Cough and Angiotensin Converting Enzyme Inhibitor therapy, a review of literature and pathophisiology. Ann Inter. Med. 117:234
242.
Nice, C. K. S. (2010). Clinical guidelines on diabetes mellitus type II.
Shaid, S., Akram, H., Jaeed, M. and Mahbood, T.
(2004) similar nature of ionic imbalance in cardiovascular and renal disorders, Pakistan Journal of
medicine 4th edition, Oxford University Press. Vol.
2, 15:1165 1198.
Whitby, L. G., Percy Robb, I. W. and Smith,
A. F. (1984). Lecture notes on clinical chemistry
3rd edition, Blackwell scientic publication, Oxford
20:301 304.
White, W. L. Skeggs, L. T. and Hochstrasser, H. C.
(1970). Chemistry of technologist, 3rd edition C.
V. Mosby co. st. Louise, 4:182 183.
William, G. H., Weir, M. R. and Ruddly, I. B.
(1988). Converting enzyme inhibitors in the treatment of diabetes mellitus. N. Engl. Journal on
medicine, 319: 174 179.
Zelmanovitz, T., Grechman, F., Balthazar, A. P.
(2009). Diabetic nephropathy. Diabetol metab
synd. 21:1 10.

12 External links
Diabetic nephropathy. HealthCentral.
Diabetic nephropathy. MedlinePlus Medical Encyclopedia. Text from this public domain article was
partially used here.
Texas University Classication

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