Diabetic nephropathy is a disease in which thickened tissue forms in the capillaries of the kidneys and kidney failure develops. One of the factors causing this disease is an increase in pressure in the capillaries of the kidneys.
The main cause of the disease (diabetic nephropathy) is excess glucose, as it causes destruction of the walls of blood vessels and leads to their permeability. Structural changes occur in all organs.
As practice shows, mortality with type 1 diabetes is much higher from kidney diseases than with type 2 diabetes, in which death occurs from heart and vascular diseases.
1.What is diabetic nephropathy?
Nephropathy
is a kidney disease.
Diabetic nephropathy
means that kidney problems are caused by diabetes. In severe cases, diabetic nephropathy can lead to kidney failure.
The kidneys contain many tiny blood vessels that filter the blood. High blood sugar due to diabetes can destroy these blood vessels. Over time, the kidneys cannot cope with their work, and sometimes stop working completely. Then kidney failure
. It is worth knowing that not all people with diabetes develop diabetic nephropathy. Why this is so is still not known exactly.
Several factors increase the likelihood of diabetic nephropathy.
If you have high blood pressure, high cholesterol, or smoke, your risk increases.
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Development mechanism
Diabetic nephropathy has several theories of pathogenesis, which are divided into metabolic, hemodynamic and genetic.
The trigger point for this complication in the hemodynamic and metabolic versions is hyperglycemia, long-term insufficient compensation of pathological processes in carbohydrate metabolism.
Symptoms of hyperglycemia
Hemodynamic. Hyperfiltration occurs, and later there is a decrease in renal filtration work and an increase in connective tissue.
Metabolic. Prolonged hyperglycemia leads to biochemical disorders in the kidneys.
Hyperglycemia is accompanied by the following dysfunctions:
- glycation of proteins occurs with an increased content of glycated hemoglobin;
- the sorbitol (polyol) shunt is activated - the absorption of glucose regardless of insulin. The process of converting glucose into sorbitol and then oxidizing it into fructose occurs. Sorbitol accumulates in tissues and causes microangiopathy and other pathological changes;
- impaired transport of cations.
With hyperglycemia, it activates the enzyme protein kinase C, which leads to tissue proliferation and the formation of cytokines. There is a disruption in the synthesis of complex proteins - proteoglycans and damage to the endothelium.
With hyperglycemia, intrarenal hemodynamics are disrupted, causing sclerotic changes in the kidneys. Long-term hyperglycemia is accompanied by intraglomerular hypertension and hyperfiltration.
The cause of intraglomerular hypertension is the abnormal state of the arterioles: dilated afferent and toned efferent. The change becomes systemic and aggravates impaired renal hemodynamics.
As a result of prolonged pressor action in the capillaries, vascular and parenchymal renal structures are disrupted. Lipid and protein permeability of basement membranes increases. Deposition of proteins and lipids in the intercapillary space is observed, atrophy of the renal tubules and sclerosis of the glomeruli are observed. As a result, urine is not filtered sufficiently. There is a change from hyperfiltration to hypofiltration, and the progression of proteinuria. The end result is a disruption of the renal excretory system and the development of azothermia.
When hyperlycemia is detected, the theory developed by geneticists suggests a special influence of genetic factors on the renal vascular system.
Glomerular microangiopathy can also be caused by:
- arterial hypertension and hypertension;
- prolonged uncontrolled hyperglycemia;
- urinary tract infection;
- abnormal fat balance;
- overweight;
- bad habits (smoking, alcohol abuse);
- anemia (low concentration of hemoglobin in the blood);
- use of drugs that have a nephrotoxic effect.
3. Diagnosis and treatment of the disease
Early stage diabetic nephropathy
practically does not appear at all.
Therefore, it is very important for people with diabetes to have regular urine tests
to detect kidney damage at an early stage. In this case, there is a chance to cope with the problem.
Diabetic nephropathy is diagnosed using a simple urine test, which, if the disease is present, will show the presence of the protein albumin. Urine usually does not contain protein. But in the early stages of kidney disease, before symptoms appear, protein can be found in the urine because the kidneys cannot filter it out properly. Such early diagnosis and treatment can prevent the progression of diabetic nephropathy.
Treatment of diabetic nephropathy
aims to lower blood pressure and prevent or slow kidney damage.
Medicines prescribed for these purposes are angiosin-converting enzyme inhibitors (ACE inhibitors) and angiotensin II receptor blockers
.
As kidney disease progresses, blood pressure
. Cholesterol and triglyceride levels also become too high. Special medications may be needed to treat these complications of diabetic nephropathy.
There are other steps you can take to treat diabetic nephropathy:
- Monitor your blood sugar levels. This will help slow down damage to the small blood vessels in the kidneys;
- Contact a good doctor who can help you keep your blood pressure normal. For people with diabetes, a blood pressure of 120/80 is considered ideal. And a figure above 140/80 is already high blood pressure.
- Keep your heart healthy. Eating right and exercising is very important and healthy. Preventing heart disease is important because people with diabetes are more likely to have cardiovascular problems.
- Limit protein foods in your diet. Its excess creates increased stress on the kidneys. For diabetic nephropathy, reducing protein intake will help preserve kidney function.
- Don't eat a lot of salt. This will prevent arterial hypertension from progressing.
- Do not smoke.
The best way to prevent kidney damage from early diabetic nephropathy is to control your blood sugar and blood pressure. All this is achieved with regular healthy eating, exercise, weight control and taking medications if recommended by your doctor. In addition to a healthy lifestyle, medications are also used in the treatment of diabetic nephropathy. Your doctor may prescribe medications that lower your blood pressure and protect your kidneys at the first sign of protein in your urine.
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Possible causes of nephropathy and diagnosis
When glucose levels increase, it begins to poison human organs. Filtration in the kidneys is worse. As a result, blood flow weakens, sodium ions accumulate in it, causing vasoconstriction, leading to increased pressure and kidney damage. There are three theories about the development of the disease:
- Genetic – hereditary predisposition.
- Hemodynamic – renal circulation is impaired.
- Metabolic - all problems are caused by elevated glucose levels, which leads to disruption of blood flow and metabolic processes.
Conventional tests cannot diagnose stages 1 to 3 of the disease. It is necessary to make regular measurements of urine albumin and filtration rate. In the fourth and fifth stages, the clinical picture changes and protein in the urine increases, arterial hypertension manifests itself, visual impairment occurs due to diseases of the eye vessels, and the filtration rate decreases. Diagnosis is carried out on the basis of basic indicators: the type and “age” of diabetes and laboratory test results.
4.What if diabetic nephropathy progresses?
As diabetic nephropathy progresses, blood pressure usually increases, meaning more medications are needed to control it.
Your doctor may recommend one or a combination of the following medications:
- A combination of angiotensin-converting enzyme and angiotensin receptor blockers. The combination of these drugs can have a greater effect in lowering blood pressure than taking them individually.
- Calcium channel blockers lower blood pressure and help blood flow better through the vessels.
- Diuretics will help lower blood pressure by removing sodium and water from the body;
- Beta blockers lower blood pressure by slowing the heartbeat and reducing the amount of blood that will be pumped with each heartbeat.
If you have diabetic nephropathy, it is important to avoid medications that can harm your kidneys (especially nonsteroidal anti-inflammatory drugs). And even if you are undergoing treatment, it is important to control your blood sugar levels and lead a healthy lifestyle, the rules of which we discussed above.
Characteristics of the complication
In diabetic nephropathy, the kidney vessels, arteries, arterioles, glomeruli and tubules are affected. Pathology causes disturbed carbohydrate and lipid balance. The most common occurrence is:
- Arteriosclerosis of the renal artery and its branches.
- Arteriolosclerosis (pathological processes in arterioles).
- Diabetic glomerulosclerosis: nodular - the renal glomeruli are filled with round or oval formations completely or partially (Kimmelstiel-Wilson syndrome); exudative - capillary loops on the glomerular lobules are covered with rounded formations that look like caps; diffuse – the basement membranes of the capillaries are thickened, the mesangium is expanded and compacted, nodules are not observed.
- Fat and glycogen deposits in the tubules.
- Pyelonephritis.
- Necrotizing renal papillitis (necrosis of the renal papillae).
- Necrotic nephrosis (necrotic changes in the epithelium of the renal tubules).
Diabetic nephropathy in the medical history is diagnosed as chronic kidney disease (CKD) with specification of the stage of the complication.
Pathology in diabetes mellitus has the following code according to ICD-10 (International Classification of Diseases, 10th revision):
- E 10.2 – for an insulin-dependent form of the disease, aggravated by diseased kidneys.
- E 11.2 – for insulin-independent disease and renal failure.
- E 12.2 – for malnutrition and damaged kidneys.
- E 13.2 – for specified forms of the disease and unhealthy kidneys.
- E 14.2 – for an unspecified form with kidney damage.
Diabetes
Diabetic nephropathy is treated with medications that lower blood pressure and protect the kidneys. These drugs can reverse the progression of kidney damage and should be started as soon as any amount of protein is detected in the urine (microalbuminuria). Using medications in this group before the onset of nephropathy can also prevent its development in people with normal blood pressure.
If you have high blood pressure, you may need to take two or more medications to lower your blood pressure without damaging your kidneys. Medications may be added over time as needed. The American Diabetes Association recommends a blood pressure goal of less than 130/80 millimeters of mercury (mmHg). The level recommended by other organizations may vary. Talk to your doctor about your target blood pressure level. For more information about medications that lower blood pressure, see the section on High Blood Pressure (Hypertension).
If you are taking other medications, avoid those that may damage your kidneys, especially nonsteroidal anti-inflammatory drugs (NSAIDs).
It is also necessary to ensure that your blood sugar levels are as close to normal as possible. This prevents damage to the small blood vessels in the kidneys.
Limiting the amount of salt you eat can help prevent your high blood pressure from getting worse. You may also want to limit the amount of protein in your diet. Most doctors recommend that the amount of protein in your diet be no more than 10% of your daily calories. Consult a nutritionist if you need help creating a balanced diet for yourself.
People with diabetes are 2 to 4 times more likely to die from heart and blood vessel disease. Taking low-dose aspirin and following a low-fat diet may help prevent heart attack, stroke, and diseases of other large blood vessels (macrovascular disease).
Initial treatment
Medicines that are used to treat diabetic nephropathy are also used to control blood pressure. If you have small amounts of protein in your urine, these medications may reverse the progression of kidney damage. Medications that may be used for initial treatment of diabetic nephropathy may include:
- Angiotensin-converting enzyme (ACE) inhibitors
such as captopril, lisinopril, ramipril and enalapril. They showed protection for kidney function in people with type 1 diabetes, even those without high blood pressure. ACE inhibitors may reduce urinary protein loss. They may also reduce your risk of developing heart and blood vessel disease (cardiovascular disease). One study found that ramipril reduced the risk of developing cardiovascular disease in people with diabetes (both type 1 and 2) by 25-30%. - Angiotensin II receptor blockers (ARBs)
, such as candesartan, irbesaratan, losartan and telmisartan. You may be prescribed ACE inhibitors and ARAs. A combination of these drugs may provide more protection for your kidneys than either drug alone.
If you have high blood pressure, you may need to take two or more medications to lower your blood pressure without damaging your kidneys. Medications may be added over time as needed. The American Diabetes Association recommends a blood pressure goal of less than 130/80 millimeters of mercury (mmHg).
If you are taking other medications, avoid those that may damage your kidneys, especially nonsteroidal anti-inflammatory drugs (NSAIDs).
You also need to ensure that your blood sugar levels are as close to normal as possible. This prevents damage to the small blood vessels in the kidneys. The American Diabetes Association recommends keeping your blood sugar at:
- 70-130 mg/dL (3.8-7.2 mmol/L) on an empty stomach and 110-150 mg/dL (6.1-8.3 mmol/L) at bedtime.
- Less than 180 mg/dL (10 mmol/L) 1-2 hours after meals.
People with diabetes are 2 to 4 times more likely to die from heart and blood vessel disease. Eating a low-fat diet may help prevent heart attack, stroke, and diseases of other large blood vessels (macrovascular disease).
Limiting the amount of salt you eat can help prevent your high blood pressure from getting worse. You may also want to limit the amount of protein in your diet. Most doctors recommend that the amount of protein in your diet be no more than 10% of your daily calories. Consult a nutritionist if you need help creating a balanced diet for yourself.
Maintenance treatment
As diabetic nephropathy progresses, blood pressure increases, which leads to the need to prescribe additional medications to control it. The American Diabetes Association recommends a target blood pressure level of less than 130/80 mmHg because this level can protect your kidneys. The level recommended by other organizations may differ from this. Discuss your personal blood pressure goal with your doctor.
Your doctor may recommend that you take the following medications to lower your blood pressure. You may need to take different combinations of these drugs to better control your blood pressure. By lowering your blood pressure, you can reduce your risk of kidney damage. Such medications are:
- A combination of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers.
A combination of these drugs may provide more protection for your kidneys than either drug alone.
- Calcium channel blockers
lower blood pressure by facilitating the movement of blood through the vessels. Examples of such drugs are diltiazem (Diacordin), verapamil (Isoptin, Lekoptin), amlodipine (Norvasc, Stamlo, Amlo) and nifedipine (Corinfar, Adalat).
- Diuretics.
Drugs such as chlorthalidone, hydrochlorothiazide, or spironolactone help lower blood pressure by removing sodium and water from the body.
- Beta blockers
lower blood pressure by slowing the heart rate and reducing the amount of blood pumped out with each beat. Representatives of this group of drugs are atenolol, carvedilol or metoprolol.
If you are taking other medications, avoid those that may damage your kidneys, especially nonsteroidal anti-inflammatory drugs (NSAIDs).
It is also necessary to ensure that your blood sugar levels are as close to normal as possible. This prevents damage to the small blood vessels in the kidneys. The American Diabetes Association recommends keeping your blood sugar at:
- 70-130 mg/dL (3.8-7.2 mmol/L) on an empty stomach and 110-150 mg/dL (6.1-8.3 mmol/L) at bedtime.
- Less than 180 mg/dL (10 mmol/L) 1-2 hours after meals.
People with diabetes are 2 to 4 times more likely to die from heart and blood vessel disease. Eating a low-fat diet may help prevent heart attack, stroke, and diseases of other large blood vessels (macrovascular disease).
Limiting the amount of salt you eat can help prevent your high blood pressure from getting worse. You may also want to limit the amount of protein in your diet. Most doctors recommend that the amount of protein in your diet be no more than 10% of your daily calories. Consult a nutritionist if you need help creating a balanced diet for yourself.
People with diabetic nephropathy also have an increased risk of illness and death from heart disease, so you should follow your doctor's recommendations to reduce this risk. Strategies include maintaining your cholesterol levels at a normal level, using low-dose aspirin, exercising regularly, and stopping smoking if you have smoked before.
Treatment if the condition worsens
If damage to the blood vessels in the kidneys continues, kidney failure develops over time. When this happens, dialysis treatment (kidney replacement therapy), an artificial method of filtering the kidneys, is necessary for you to survive; or in kidney transplantation.
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Genetic causes
On the genetic side, people with diabetic nephropathy have genetically determined predisposing causes, which recur with metabolic and hemodynamic failures.
Among the causes of diabetic nephropathy are:
- arterial hypertension;
- prolonged hyperglycemia;
- urinary tract infection;
- obesity;
- smoking;
- use of nephrotoxic drugs.
Second stage
The clinical picture of diabetic nephropathy becomes pronounced after ten years in the first type of diabetes mellitus and manifests itself in the form of persistent proteinuria, which indicates the irreversibility of the damage. Nephrotic syndrome also develops - massive proteinuria, protein-lipid metabolism is disrupted and edema appears. With nephrotic syndrome, hypoalbuminemia, dysproteinemia, edema of various localizations, degenerative changes in the skin and mucous membranes occur. Creatinine and urea in the blood are at normal levels or slightly elevated.
Third stage
At the terminal stage of diabetic nephropathy, the filtration and concentration work of the kidneys decreases, this is massive proteinuria, and an increase in creatinine and urea in the blood. Anemia and edema develop. This stage is characterized by a slight decrease in hyperglycemia and glucosuria, and the emergence of a need for exogenous insulin. Nephrotic syndrome begins to progress, and dyspeptic syndrome, uremia and chronic renal failure with signs of poisoning with its own metabolic products also form.
Arterial hypertension
The hemodynamic theory in the development of diabetic nephropathy is determined by arterial hypertension - a secondary hypertensive condition that develops with pathology of the organs that regulate blood pressure. Arterial hypertension is characterized by resistance to antihypertensive therapy and the development of striking changes in target organs.
Long-term arterial hypertension leads to changes, first from hyperfiltration with accelerated formation of primary urine and the manifestation of proteins, then the tissue of the renal glomerulus is replaced by connective tissue with complete occlusion of the glomeruli. This development leads to chronic renal failure.
