Diabetic Nephropathy

Original Editor - Oluwafikunayomi Wole-Bankole and Kadeba Bisola|Kadeba Bisola

Top Contributors - Oluwafikunayomi Wole-Bankole and Tolulope Adeniji  

ORIGINAL EDITORS: Oluwafikunayomi Wole-Bankole and Kadeba Bisola as part of the Redeemer's University Physioculture Journal Project

DIABETIC NEPHROPATHY

Diabetic nephropathy also known as chronic kidney disease is a condition characterized by excessive urine albumin, diabetic glomerular lesions, and a decline in glomerular filtration rate in diabetics.   In most developed countries, diabetes nephropathy is the most common cause of end-stage renal disease and it affects about a 40% of people with diabetes (2). Diabetes nephropathy is linked with a high cardiovascular death rate (3).  It has been classified into various phases:  microalbuminuria (UAE >20 μg/min and ≤199 μg/min) and macroalbuminuria (UAE ≥200 μg/min). Depending on the type of diabetes and whether microalbuminuria (defined as >30 mg but 300 mg albumin in the urine per day) is present, the natural course of diabetic nephropathy varies. 80% of individuals with type 1 diabetes and microalbuminuria who are neglected will eventually develop overt nephropathy whereas about 20–40% of people with type 2 diabetes will progress into nephropathic stage (4). Diabetic nephropathy is one of the causes of chronic kidney disease.

EPIDEMIOLOGY

Between 10 and 15 years following the commencement of the disease, type 1 diabetes patients have their peak nephropathy development. According to previous reports, type 2 diabetic patients have a reduced prevalence of progressive renal disease. The prevalence of diabetic nephropathy is increasing. Globally, the prevalence of diabetes was about 171 million in 2000, increasing to 382 million in 2013; and is projected to reach 592 million by 2035 (5). DN is now the most common cause of end-stage renal disease (ESRD) in most countries because of the diabetes epidemic. In Malaysia, Mexico, and Singapore, diabetes accounted for 60% of cases of ESRD between 2009 and 2011. In 2015, it was predicted that 415 million individuals globally had diabetes; by 2040, it is expected to rise to 642 million, with a significant rise in low- and middle-income nations.

PATHOPHYSIOLOGY

In diabetes both Type I and Type II diabetes have similar effects on the kidney, as an increase in glucose levels in the blood damages blood vessels including the arteries that supply the kidney. The nephrons of the kidneys are also affected as they begin the thicken and become scared (6). They also begin to leak the protein contents that are supposed to pass out with urine. Over time this leads to kidney nephropathy (7).

CLINICAL MANIFESTATIONS

Due to diabetes, there is an onset of kidney failure and the symptoms of do not manifest until its end stages (between five-ten years) (8). The symptoms of end stage kidney damage include:

1.     Swelling

2.     Itching

3.     Nausea

4.     Vomiting

5.     Shortness of breath due to the accumulation of fluid in the lungs as a result of kidney failure (9)

6.     Hypertension

7.     Weight loss due to loss of appetite.

8.     Bone pain in kidney failure is also known renal osteodystrophy.  This occurs in diabetic nephropathy due to reduction in minerals and hormones in the blood required for the bone growth, bone growth is thus hindered causing pain in the bones and lead to fractures (10).

9.     Chest Pain: due to the reduction in minerals contents, the heart does more work to pump blood through the body. This also increases stress on arteries and the cardiovascular system at large. Also, the lining of the heart can also become inflamed which causes chest pain (9)

10.  Cardiovascular diseases are common in diabetic patients with chronic kidney disease and this is due to the decreased estimated glomerular filtration rate and decreased levels of albuminuria (11). Low grade albuminuria levels or reduced albuminuria is said to be an indicator for cardiovascular diseases as it represents that there is an indication of vascular disorders of the kidney and vascular beds (12).

DIAGNOSIS

Diagnosis of chronic kidney diseases in individuals with type 2 diabetics is done with a simple cost-effective kidney test which is represented by eGFR determination in the serum and urine albumin (13)

MEDICAL MANAGEMENT

The major management of the condition is the prevention of various cardiovascular diseases such as hypertension as reduced albuminuria causes disturbances to cardiovascular health (14). The use of precision medicine which puts into consideration the individuality of diseases and various treatment strategies required, this form of medicine characterizes diseases based on underlying molecular pathology(13).

Reduction of dietary proteins and achieving close to normal or normal blood glucose levels (15).

Oral hypoglycemic agents such as SGLT2 reduces re-absorption in the kidney, hence causing excretion of glucose and reducing hyperglycemia and the use of angiotensin-converting enzyme inhibitors are used to control blood pressure (16).

PHYSIOTHERAPY MANAGEMENT

Physiotherapy management involves the control of blood pressure, obesity and diabetes. This is done by enhancing cardiovascular health, improving circulation and reducing blood sugar and body fat levels. Aerobic exercises (Low to moderate) such as swimming and cycling and stretching exercises (17)

Exercises slow the progression of kidney diseases, reduce vascular endothelial function and high-intensity exercises lead to hypoperfusion and proteinuria in renal disease due to arteriolar vasoconstrictor actions (18).

Cautions during management to ensure proper foot care, do not engage in exercise when blood sugar levels are higher than 250mg/dl and less than 100mg/dl (19). Also, patients are advised not to participate in exercise with a blood pressure 180/110mmHg (20).

REFERENCES

1. Pálsson R, Patel UD. Cardiovascular complications of diabetic kidney disease. Vol. 21, Advances in Chronic Kidney Disease. W.B. Saunders; 2014. p. 273–80.

2. Wang G, Ouyang J, Li S, Wang H, Lian B, Liu Z, et al. The analysis of risk factors for diabetic nephropathy progression and the construction of a prognostic database for chronic kidney diseases. J Transl Med. 2019 Aug 13;17(1):264.

3. Valmadrid CT, Klein R, Moss SE, Klein BEK. The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. Arch Intern Med [Internet]. 2000 Apr 24 [cited 2022 Oct 2];160(8):1093–100. Available from: https://pubmed.ncbi.nlm.nih.gov/10789601/

4. Dronavalli S, Duka I, Bakris GL. The pathogenesis of diabetic nephropathy. Nature Clinical Practice Endocrinology & Metabolism 2008 4:8 [Internet]. 2008 Jul 8 [cited 2022 Oct 2];4(8):444–52. Available from: https://www.nature.com/articles/ncpendmet0894

5. Lim AKH. Diabetic nephropathy – complications and treatment. Int J Nephrol Renovasc Dis [Internet]. 2014 Oct 15 [cited 2022 Oct 2];7:361. Available from: /pmc/articles/PMC4206379/

6. Diabetes and Chronic Kidney Disease | CDC [Internet]. [cited 2023 Jan 22]. Available from: https://www.cdc.gov/diabetes/managing/diabetes-kidney-disease.html

7. American Diabetes Association Professional Practice Committee. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S185–94.

8. Diabetes and kidney disease: MedlinePlus Medical Encyclopedia [Internet]. [cited 2022 Oct 2]. Available from: https://medlineplus.gov/ency/article/000494.htm

9. Negi S, Koreeda D, Kobayashi S, Yano T, Tatsuta K, Mima T, et al. Acute kidney injury: Epidemiology, outcomes, complications, and therapeutic strategies. Vol. 31, Seminars in Dialysis. Blackwell Publishing Inc.; 2018. p. 519–27.

10. Renal Osteodystrophy: Causes, Symptoms & Treatment [Internet]. [cited 2023 Jan 27]. Available from: https://my.clevelandclinic.org/health/diseases/24006-renal-osteodystrophy

11. Pálsson R, Patel UD. Cardiovascular complications of diabetic kidney disease. Vol. 21, Advances in Chronic Kidney Disease. W.B. Saunders; 2014. p. 273–80.

12. Weir MR. Microalbuminuria and cardiovascular disease. Vol. 2, Clinical Journal of the American Society of Nephrology. Clin J Am Soc Nephrol; 2007. p. 581–90.

13. Fliser D, Wanner C. Precision medicine in diabetic nephropathy and chronic kidney disease. Nephrology Dialysis Transplantation [Internet]. 2021 Jun 22 [cited 2023 Jan 29];36(Supplement_2):10–3. Available from: https://academic.oup.com/ndt/article/36/Supplement_2/10/6307406

14. Foggensteiner L, Mrcp BM, Mulroy S, Mrcp DM, Firth J, Frcp DM. Management of diabetic nephropathy. Vol. 94, J R Soc Med. 2001.

15. De Boer IH, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K, et al. Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment. Kidney Int. 2020 Oct 1;98(4):839–48.

16. Kim MK. Treatment of diabetic kidney disease: current and future targets. Korean J Intern Med [Internet]. 2017 Jul 1 [cited 2023 Jan 29];32(4):622. Available from: /pmc/articles/PMC5511942/

17. Billinger SA, Sisante JF v., Alqahtani AS, Pasnoor M, Kluding PM. Aerobic exercise improves measures of vascular health in diabetic peripheral neuropathy. International Journal of Neuroscience. 2017 Jan 2;127(1):80–5.

18.  Amaral LS de B, Souza CS, Lima HN, Soares T de J. Influence of exercise training on diabetic kidney disease: A brief physiological approach. Exp Biol Med [Internet]. 2020 Jul 1 [cited 2023 Jan 29];245(13):1142. Available from: /pmc/articles/PMC7400720/

19.        Diabetes - Physiopedia [Internet]. [cited 2023 Jan 29]. Available from: https://www.physio-pedia.com/Diabetes

20.        Ghadieh AS, Saab B. Clinical Review Evidence for exercise training in the management of hypertension in adults.