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This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2011) |
| Diabetic nephropathy |
| Classification and external resources |
Photomicrography of nodular glomerulosclerosis in Kimmelstein-Wilson syndrome. Source: CDC |
| ICD-10 |
E10.2, E11.2, E12.2, E13.2, E14.2 |
| ICD-9 |
250.4 |
| MeSH |
D003928 |
Diabetic nephropathy (nephropatia diabetica), also known as Kimmelstiel-Wilson 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 diffuse glomerulosclerosis. It is due to longstanding diabetes mellitus, and is a prime indication for dialysis in many Western countries.
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Contents
- 1 History
- 2 Epidemiology
- 3 Pathophysiology
- 4 Signs and symptoms
- 5 Treatment
- 6 Prognosis
- 7 Complications
- 8 See also
- 9 Additional images
- 10 References
- 11 External links
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History
The syndrome was discovered by British physician Clifford Wilson (1906–1997) and German-born American physician Paul Kimmelstiel (1900–1970) and was published for the first time in 1936.[2]
Epidemiology
The syndrome can be seen in patients with chronic diabetes (usually less than 15 years after onset) after about 5 years in type 1 diabetes. Clinical nephropathy secondary to glomerular disease usually manifests 15–25 years after diagnosis of diabetes and affects 25-35% of patients under the age of 30 years. It is the leading cause of premature death in young diabetic patients.(between 50 and 70 years old). The disease is progressive and may cause death two or three years after the initial lesions, and is more frequent in men. Diabetic nephropathy is the most common cause of chronic kidney failure and end-stage kidney disease in the United States. People with both type 1 and type 2 diabetes are at risk. The risk is higher if blood-glucose levels are poorly controlled. Furthermore, 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 blood have much more risk than others.
Pathophysiology
The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. 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 nonspecific chronic changes.
Signs and symptoms
Kidney failure provoked by glomerulosclerosis leads to fluid filtration deficits and other disorders of kidney function. There is an increase in blood pressure (hypertension) and fluid retention in the body plus a reduced plasma oncotic pressure causes 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
- foamy appearance or excessive frothing of the urine (caused by the proteinuria)
- unintentional weight gain (from fluid accumulation)
- anorexia (poor appetite)
- nausea and vomiting
- malaise (general ill feeling)
- fatigue
- headache
- frequent hiccups
The first laboratory abnormality is a positive microalbuminuria test. Most often, the diagnosis is suspected when a routine urinalysis of a person with diabetes shows too much protein in the urine (proteinuria). The urinalysis may also show glucose in the urine, especially if blood glucose is poorly controlled. Serum creatinine and BUN may increase as kidney damage progresses.
A kidney biopsy confirms 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.
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 effects 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 effect is related to the antihypertensive effects in normal and hypertensive patients, renal vasodilatation resulting in increased renal blood flow and dilatation of the efferent arterioles.[3] Many studies have shown that related drugs, angiotensin receptor blockers (ARBs), have a similar benefit. However, combination therapy, according to the ONTARGET study,[4] is known to worsen major renal outcomes, such as increasing serum creatinine and causing a greater decline in estimated glomerular filtration rate (eGFR).
Blood-glucose levels should be closely monitored and controlled. This may slow the progression of the disorder, especially in the very early ("microalbuminuria") stages. Medications to manage diabetes include oral hypoglycemic agents and insulin injections. As kidney failure progresses, less insulin is excreted, so lesser doses may be needed to control glucose levels.
Diet may be modified to help control blood-sugar levels.[4] Modification of protein intake can affect hemodynamic and nonhemodynamic injury.
High blood pressure should be aggressively treated with antihypertensive medications, in order to reduce the risks of kidney, eye, and blood vessel damage in the body. It is also very important to control lipid levels, maintain a healthy weight, and engage in regular physical activity.
Patients with diabetic nephropathy should avoid taking the following drugs:
- Contrast agents containing iodine
- Commonly used non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen, or COX-2 inhibitors like celecoxib, because they may injure the weakened kidney.
Urinary tract and other infections are common and can be treated with appropriate antibiotics.
Dialysis may be necessary once end-stage renal disease develops. At this stage, a kidney transplantation must be considered. Another option for type 1 diabetes patients is a combined kidney-pancreas transplant.
C-peptide, a by-product of insulin production, may provide new hope for patients suffering from diabetic nephropathy.[5]
Currently, several compounds are in development for diabetic kidney disease. These include, but are not limited to, bardoxolone methyl,[6] olmesartan medoxomil, sulodexide, and avosentan.[7]
Silymarin
Addition of silymarin (milk thistle extract), a herbal drug with potent antioxidant and anti-inflammatory properties, to renin angiotensin inhibitors has been recently shown to be effective in reducing proteninuria in diabetic patients with overt nephropathy. [8]
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.
Complications
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
- complications of kidney transplant
- coexistence of other diabetes complications
- peritonitis (if peritoneal dialysis used)
- increased infections
See also
- Diabetic diet
- Hyperbaric medicine
- Nephrology
Additional images
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Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. H&E stain.
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Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. Another glomerulus. H&E stain.
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Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. Another glomerulus. H&E stain.
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Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAS stain.
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Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAS stain.
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Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAM stain.
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Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAM stain.
References
- ^ Berkman, James; Rifkin, Harold (1973). "Unilateral nodular diabetic glomerulosclerosis (Kimmelstiel-Wilson): Report of a case". Metabolism (Elsevier Inc.) 22 (5): 715–722. doi:10.1016/0026-0495(73)90243-6. PMID 4704716.
- ^ Kimmelstiel P, Wilson C. Benign and malignant hypertension and nephrosclerosis. A clinical and pathological study. Am J Pathol 1936;12:45-48.
- ^ Diabetes Mellitus and Angiotensin Converting Enzyme Inhibitors
- ^ a b The ONTARGET Investigators; Yusuf, S; Teo, KK; Pogue, J; Dyal, L; Copland, I; Schumacher, H; Dagenais, G et al. (2008). "Telmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events". New England Journal of Medicine 358 (15): 1547–59. doi:10.1056/NEJMoa0801317. PMID 18378520.
- ^ Wahren J, Ekberg K, Jörnvall H (2007). "C-peptide is a bioactive peptide". Diabetologia 50 (3): 503–9. doi:10.1007/s00125-006-0559-y. PMID 17235526.
- ^ http://www.medscape.com/viewarticle/590644
- ^ http://www.medicalnewstoday.com/articles/139028.php
- ^ Effect of Addition of Silymarin to Renin-Angiotensin System Inhibitors on Proteinuria in Type 2 Diabetic Patients With Overt Nephropathy: A Randomized, Double-Blind, Placebo-Controlled Trial.Fallahzadeh MK, Dormanesh B, Sagheb MM, Roozbeh J, Vessal G, Pakfetrat M, Daneshbod Y, Kamali-Sarvestani E, Lankarani KB. Am J Kidney Dis. 2012 Jul 7. [Epub ahead of print][1],
External links
- Diabetic nephropathy. HealthCentral.
- Diabetic nephropathy. MedlinePlus Medical Encyclopedia. Text from this public domain article was partially used here.
- Texas University Classification
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Urinary system · Pathology · Urologic disease / Uropathy (N00–N39, 580–599)
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| Abdominal |
Nephropathy/
(nephritis+
nephrosis) |
Glomerulopathy/
glomerulitis/
(glomerulonephritis+
glomerulonephrosis) |
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Primarily
nephrotic
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Non-proliferative
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Minimal change · Focal segmental · Membranous
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Proliferative
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Mesangial proliferative · Endocapillary proliferative Membranoproliferative/mesangiocapillary
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By condition
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Diabetic · Amyloidosis
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Type I RPG/Type II hypersensitivity
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Goodpasture's syndrome
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Type II RPG/Type III hypersensitivity
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Post-streptococcal · Lupus (DPN) · IgA/Berger's
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Type III RPG/Pauci-immune
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Wegener's granulomatosis · Microscopic polyangiitis · Churg-Strauss Syndrome
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Tubulopathy/
tubulitis
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Proximal
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RTA (RTA 2) · Fanconi syndrome
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Thick ascending
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Bartter syndrome
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Distal convoluted
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Gitelman syndrome
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Collecting duct
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Liddle's syndrome · RTA (RTA 1) · Diabetes insipidus (Nephrogenic)
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Renal papilla
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Renal papillary necrosis
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Major calyx/pelvis
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Hydronephrosis · Pyonephrosis · Reflux nephropathy
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Any/all
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Acute tubular necrosis
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Interstitium
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Interstitial nephritis (Pyelonephritis, Danubian endemic familial nephropathy)
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Any/all
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General syndromes
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Renal failure (Acute renal failure, Chronic renal failure) · Uremic pericarditis · Uremia
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Vascular
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Renal artery stenosis · Renal Ischemia · Hypertensive nephropathy · Renovascular hypertension · Renal Cortical Necrosis
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Other
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Analgesic nephropathy · Renal osteodystrophy · Nephroptosis · Abderhalden-Kaufmann-Lignac syndrome
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Ureter
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Ureteritis · Ureterocele · Megaureter
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| Pelvic |
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Bladder
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Cystitis (Interstitial cystitis, Hunner's ulcer, Trigonitis, Hemorrhagic cystitis) · Neurogenic bladder · Bladder sphincter dyssynergia · Vesicointestinal fistula · Vesicoureteral reflux
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Urethra
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Urethritis (Non-gonococcal urethritis) · Urethral syndrome · Urethral stricture/Meatal stenosis · Urethral caruncle
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| Any/all |
Obstructive uropathy · Urinary tract infection · Retroperitoneal fibrosis · Urolithiasis (Bladder stone, Kidney stone, Renal colic) · Malacoplakia · Urinary incontinence (Stress, Urge, Overflow)
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noco/acba/cong/tumr, sysi/epon, urte
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proc/itvp, drug (G4B), blte, urte
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Endocrine pathology: endocrine diseases (E00–E35, 240–259)
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Pancreas/
glucose
metabolism |
| Hypofunction |
- types:
- type 1
- type 2
- MODY 1 2 3 4 5 6
- complications
- coma
- angiopathy
- ketoacidosis
- nephropathy
- neuropathy
- retinopathy
- cardiomyopathy
- insulin receptor (Rabson–Mendenhall syndrome)
- Insulin resistance
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| Hyperfunction |
- Hypoglycemia
- beta cell (Hyperinsulinism)
- G cell (Zollinger–Ellison syndrome)
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Hypothalamic/
pituitary axes |
| Hypothalamus |
- gonadotropin
- Kallmann syndrome
- Adiposogenital dystrophy
- CRH (Tertiary adrenal insufficiency)
- vasopressin (Neurogenic diabetes insipidus)
- general (Hypothalamic hamartoma)
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| Pituitary |
| Hyperpituitarism |
- anterior
- Acromegaly
- Hyperprolactinaemia
- Pituitary ACTH hypersecretion
- posterior (SIADH)
- general (Nelson's syndrome)
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| Hypopituitarism |
- anterior
- Kallmann syndrome
- Growth hormone deficiency
- ACTH deficiency/Secondary adrenal insufficiency
- GnRH insensitivity
- FSH insensitivity
- LH/hCG insensitivity
- posterior (Neurogenic diabetes insipidus)
- general
- Empty sella syndrome
- Pituitary apoplexy
- Sheehan's syndrome
- Lymphocytic hypophysitis
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| Thyroid |
| Hypothyroidism |
- Iodine deficiency
- Cretinism
- Congenital hypothyroidism
- Myxedema
- Euthyroid sick syndrome
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| Hyperthyroidism |
- Hyperthyroxinemia
- Thyroid hormone resistance
- Familial dysalbuminemic hyperthyroxinemia
- Hashitoxicosis
- Thyrotoxicosis factitia
- Graves' disease
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| Thyroiditis |
- Acute infectious
- Subacute
- De Quervain's
- Subacute lymphocytic
- Autoimmune/chronic
- Hashimoto's
- Postpartum
- Riedel's
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| Goitre |
- Endemic goitre
- Toxic nodular goitre
- Toxic multinodular goiter
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| Parathyroid |
| Hypoparathyroidism |
- Hypoparathyroidism
- Pseudohypoparathyroidism
- Pseudopseudohypoparathyroidism
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| Hyperparathyroidism |
- Primary
- Secondary
- Tertiary
- Osteitis fibrosa cystica
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| Adrenal |
| Hyperfunction |
- aldosterone: Hyperaldosteronism/Primary aldosteronism
- Conn syndrome
- Bartter syndrome
- Glucocorticoid remediable aldosteronism
- AME
- Liddle's syndrome
- 17α CAH
- cortisol: Cushing's syndrome (Pseudo-Cushing's syndrome)
- sex hormones: 21α CAH
- 11β CAH
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Hypofunction/
Adrenal insufficiency
(Addison's, WF) |
- aldosterone: Hypoaldosteronism
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| Gonads |
- ovarian: Polycystic ovary syndrome
- Premature ovarian failure
- testicular: enzymatic
- 5α-reductase deficiency
- 17β-hydroxysteroid dehydrogenase deficiency
- aromatase excess syndrome)
- Androgen receptor (Androgen insensitivity syndrome
- general: Hypogonadism (Delayed puberty)
- Hypergonadism
- Hypoandrogenism
- Hypoestrogenism
- Hyperandrogenism
- Hyperestrogenism
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| Height |
- Dwarfism/Short stature
- Laron syndrome
- Psychosocial
- Gigantism
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| Multiple |
- Autoimmune polyendocrine syndrome
- Carcinoid syndrome
- Multiple endocrine neoplasia
- Progeria
- Werner syndrome
- Acrogeria
- Metageria
- Woodhouse-Sakati syndrome
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noco (d)/cong/tumr, sysi/epon
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proc, drug (A10/H1/H2/H3/H5)
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Diabetes (E10–E14, 250)
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| Types of diabetes |
- Prediabetes
- Impaired fasting glucose
- Impaired glucose tolerance
- Type 1
- Type 1.5
- Type 2
- KPD
- MODY
- NDM
- Diabetes and pregnancy: Gestational diabetes
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| Blood tests |
- Blood sugar
- Glycosylated hemoglobin
- Glucose tolerance test
- Fructosamine
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| Diabetes management |
- Diabetic diet
- Anti-diabetic drugs
- Insulin therapy
- Glossary of diabetes
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| Complications/prognosis |
- Diabetic comas
- Diabetic hypoglycemia
- Diabetic ketoacidosis
- Hyperglycemic hyperosmolar state
- Diabetic angiopathy
- Diabetic foot
- ulcer
- neuropathic arthropathy
- Diabetic myonecrosis
- Diabetic nephropathy
- Diabetic neuropathy
- Diabetic retinopathy
- Diabetic cardiomyopathy
- Diabetic dermadrome
- Diabetic dermopathy
- Diabetic bulla
- Diabetic cheiroarthropathy
- Neuropathic ulcer
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| Lines of research |
- Embryonic stem cells
- Gastric bypass surgery
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noco (d)/cong/tumr, sysi/epon
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proc, drug (A10/H1/H2/H3/H5)
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