Diabetic kidney disease - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Diabetic kidney disease (DKD) is usually a clinical diagnosis in a patient with long-standing diabetes (>10 years) with albuminuria and/or reduced estimated glomerular filtration rate (eGFR) in the absence of signs or symptoms of other primary causes of kidney damage.
Symptoms, which may be absent until the disease is advanced, include fatigue, anorexia, and swelling of the extremities. Signs include hypertension, edema, and findings of associated microvascular complications (diabetic retinopathy and neuropathy). As patients become clinically uremic, encephalopathy, nausea and vomiting, dysgeusia (altered taste), bleeding, myoclonus, and pericarditis may be present.
Albuminuria is the characteristic laboratory finding. Deterioration in renal function may develop as the disease advances. However, the pattern of albuminuria and reduced glomerular filtration rate (GFR) is changing, and reduced GFR without albuminuria is becoming more common. Such patients usually have a better renal prognosis than those with overt albuminuria. Progression of DKD may occur even in patients in whom control of diabetes mellitus has been achieved in accordance with guidelines.
Treatment includes intensive management of hyperglycemia and treatment of hypertension with ACE inhibitors, angiotensin-II receptor antagonists, or other antihypertensives. Lipid reduction and smoking cessation may be beneficial. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are moderately to highly effective at glycemic control and very effective at reducing proteinuria and slowing the progression of DKD. Glucagon-like peptide 1 (GLP-1) receptor agonists are highly effective antidiabetic medications with benefits of moderate to marked weight loss, and their use improves kidney and cardiovascular outcomes. Finerenone is the first nonsteroidal mineralocorticoid receptor antagonist to demonstrate positive renal and cardiovascular outcomes in patients with DKD.
Complications include hypoglycemia due to intensive treatment of hyperglycemia, hyperkalemia as an adverse effect of ACE inhibitors or angiotensin-II receptor antagonists, volume depletion due to osmotic diuresis from glycosuria, and inadequate protein/caloric intake leading to malnutrition. Some patients may reach end-stage renal failure, requiring dialysis.

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Definition

Epidemiology

Etiology

Pathophysiology

Images

Diabetic kidney disease: mesangial expansion due to increased mesangial matrix and decreased degradation of glycosylated collagen
Diabetic kidney disease: mesangial expansion is usually recognized when it has exceeded 1.5 times the normal mesangial matrix
Diabetic kidney disease: at 5 o'clock - early Kimmelstiel-Wilson nodule, a rounded increase in mesangial matrix that probably originated in relation to a microaneurysm
Diabetic kidney disease: at 12 o'clock - early Kimmelstiel-Wilson nodule, a rounded form of mesangial expansion

Citations

Key Articles

American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan;47(suppl 1):S1-321.[Full Text]
Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2022 Nov;102(5s):S1-127.[Abstract][Full Text]
de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022 Dec 1;45(12):3075-90.[Abstract][Full Text]
Davies MJ, Aroda VR, Collins BS, et al. Management of hyperglycemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022 Nov 1;45(11):2753-86.[Abstract][Full Text]
Lo C, Toyama T, Wang Y, et al. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease. Cochrane Database Syst Rev. 2018 Sep 24;(9):CD011798.[Abstract][Full Text]

Other Online Resources

EBMCalc: glomerular filtration rate estimation (eGFR) by CKD-EPI equation with creatinine, without race (2021)

Referenced Articles

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