Important and common cause of morbidity and mortality in those with diabetes (develops in >30% of type 1 diabetes). Commonest cause of end stage renal failure/disease (ESRF/ESRD) in developed countries. Associated with very high risk of atherosclerosis ( ischaemic heart disease, cerebrovascular disease and peripheral vascular disease). Incidence in type 2 diabetes appears to be increasing, probably because those with diabetes are living longer as a result of better management of cardiovascular risk factors.
Main risk factors are glycaemic control, smoking and urinary albumin excretion rate.
Natural history is initially subclinical functional changes (increased renal blood flowhyperfiltration and compensatory renal hypertrophy) development of subclinical renal lesions and subclinical changes in renal vasculature microalbuminuria from leakage, increase in blood pressure loss of functional nephrons clinical nephropathy (proteinuria, nephrotic syndrome, hypertension) ESRD
Nephropathy is symptom free until it is moderately advanced. Earliest sign of tissue damage is microalbuminuria (when excretion is 30-300mg/day) – may precede frank clinical nephropathy by up to 10 years; when this exceeds 300mg/day dipstick tests become positive; peripheral oedema; hypertension is common and severe
• Routine urinalysis is often advised at diagnosis of Type 2 for possible albuminuria/proteinuria; annual screening is advisable early detection is important.
• Intensive insulin therapy (DCCT showed reduction in risk of developing of 50%); reduction of protein intake in diet; aggressive reduction of cardiovascular risk factors (especially hypertension and dyslipidaemia); ACE inhibitors (has significant effects – may delay by up to 10 years); calcium channel blockers; avoid cigarette smoking
• A decision analysis model has shown that the treatment of all patients with an ACE inhibitor could slow the progression to ESRD for a relatively low cost , but no controlled studies yet support this widespread intervention.
• Later need dialysis and maybe transplant.
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