Professional Documents
Culture Documents
Diabetic Nephropathy
Diabetic Nephropathy
Diabetes Mellitus
Group of metabolic disorders
Hyperglycemia
Adult blindness
Increased predisposition to cardiovascular diseases
Insulin Biosynthesis
Produced in the beta cells of the pancreatic islets
Cleavage of an internal 31-residue fragment from proinsulin C peptide and the A (21 amino acids) and B (30 amino acids) chains of INSULIN, connected by disulfide bonds.
Insulin Secretion
Insulin Action
Type I
Complete
Type II Others
Insulin resistance Impaired insulin secretion MODY
DM Type I
Insulin deficiency
DM Type I
Features of diabetes do not become evident until a majority of beta cells are destroyed (7080%).
DM Type II
Insulin
resistance and abnormal insulin secretion Insulin resistance precedes an insulin secretory defect but that diabetes develops only when insulin secretion becomes inadequate.
DM Type II
Diabetes mellitus
Diabetes mellitus
FPG <5.6 mmol/L (100 mg/dL), Plasma glucose <140 mg/dL (11.1 mmol/L) following an oral glucose challenge, A1C <5.6% are considered to define normal glucose tolerance
Two-hour plasma glucose 11.1 mmol/L (200 mg/dL) during an oral glucose tolerance testd
glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water
history of diabetes (i.e., parent or sibling with type 2 diabetes) Obesity (BMI 25 kg/m2) Physical inactivity Race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Previously identified with IFG, IGT, or an A1C of 5.76.4%
History
of GDM or delivery of baby >4 kg (9 lb) Hypertension (blood pressure 140/90 mmHg) HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) Polycystic ovary syndrome or acanthosis nigricans History of cardiovascular disease
Acute Complications of DM
Acute Complications of DM
Characterized by hyperglycemia, ketosis, and metabolic acidosis Ketones 5 meq/L Increased blood glucose pH < 7.3 (~6.8-7.3) Serum bicarbonate 10 mEq/L Manifestations
Acute Complications of DM
an elderly individual with type 2 DM, with a several week history of polyuria, weight loss, and diminished oral intake that culminates in mental confusion, lethargy, or coma
Manifestations
Profound Dehydration and hyperosmolality and reveals hypotension, tachycardia, and altered mental status Absent are symptoms of nausea, vomiting, and abdominal pain and the Kussmaul respirations characteristic of DKA
Diabetic Nephropathy
Leading
cause of ESRD in the US Leading cause of DM-related morbidity and mortality Microalbuminuria and macroalbuminuria associated with increased CV disease diabetic retinopathy
Pathogenesis
1
Hyperglycemia
Structural changes in the glomerulus Increased extracellular matrix, BM thickening, mesangial expansion, fibrosis
Radiocontrast-induced nephrotoxicity
Risk
factors
Treatment
Optimal
Interventions
(1) normalization of glycemia (2) strict blood pressure control (3) administration of ACE inhibitors or ARBs.
Improved
glycemic control reduces the rate at which microalbuminuria appears and progresses in type 1 and type 2 DM.
During
the later phase of declining renal function, insulin requirements may fall as the kidney is a site of insulin degradation.
Many
individuals with type 1 or type 2 DM develop hypertension. pressure should be maintained at <130/80 mmHg in diabetic individuals.
Blood
Drugs
ACE inhibitors ARBS If use of either ACE inhibitors or ARBs is not possible or the blood pressure is not controlled
calcium channel blockers (non-dihydropyridine class) beta blockers Diuretics *efficacy in slowing the fall in the GFR (?)
ADA suggestion
modest
restriction of protein intake in diabetic individuals with microalbuminuria (0.81.0 g/kg per day) or macroalbuminuria (<0.8 g/kg per day). GFR <60 mL/min per 1.743 m2 consulation!
Estimated
Hemodialysis
As compared to nondiabetic individuals, hemodialysis in patients with DM is associated with more frequent complications
hypotension (due to autonomic neuropathy or loss of reflex tachycardia) more difficult vascular access accelerated progression of retinopathy.
Atherosclerosis is the leading cause of death in diabetic individuals on dialysis hyperlipidemia should be treated aggressively.
Renal Transplantation
from
Combined pancreas-kidney transplant offers the promise of normoglycemia and freedom from dialysis.
Thank you!