Among all the complications that diabetes threatens a person, diabetic nephropathy occupies a leading place.
The first changes in the kidneys appear in the first years after diabetes, and the final stage is chronic renal failure (CRF).
But careful adherence to preventive measures, timely diagnosis and adequate treatment help to delay the development of this disease as much as possible.
Causes of the disease
Violation of the full work of the kidneys - one of the earliest effects of diabetes. After all, it is on the kidneys that the main work of cleansing the blood from excess impurities and toxins falls.
When a diabetic in the blood sharply jumps up the level of glucose, it acts on the internal organs as the most dangerous toxin. It is becoming more and more difficult for the kidneys to cope with their filtration task.
As a result, blood flow weakens, it accumulates sodium ions, which provoke the narrowing of the lumen of the renal vessels.
The pressure in them increases (hypertension), the kidneys begin to break down, which causes an even greater increase in pressure.
But despite such a vicious circle, not all patients with diabetes develop kidney damage.
Therefore, doctors identify 3 main theories that call the causes of the development of renal ailments.
- Genetic. One of the first reasons why a person gets diabetes is today called hereditary predisposition. The same mechanism is attributed to nephropathy. As soon as a person becomes ill with diabetes, mysterious genetic mechanisms accelerate the development of vascular damage in the kidneys.
- Hemodynamic. In diabetes, there is always a violation of the renal blood circulation (that is hypertension). As a result, a large number of albumin proteins appear in the urine, vessels under such pressure are destroyed, and the damaged areas are tightened with scar tissue (sclerosis).
- Exchange This theory assigns the main destructive role of elevated glucose in the blood. All vessels in the body (including the kidney) are affected by the "sweet" toxin. The vascular blood flow is disrupted, normal metabolic processes change, fats are deposited in the vessels, which leads to nephropathy.
Today, doctors in their work use the generally accepted classification by stages of diabetic nephropathy according to Mogensen (developed in 1983):
|Kidney hyperfunction||Hyperfiltration and renal hypertrophy||At the very first stage of the disease|
|First structural changes||Hyperfiltration, renal basement membrane thickens, etc.||2-5 years|
|Incipient nephropathy||Microalbuminuria, increases glomerular filtration rate (GFR)||Over 5 years|
|Severe Nephropathy||Proteinuria, sclerosis covers 50-75% of the glomeruli||10-15 years|
|Uremia||Complete glomerulosclerosis||15-20 years|
But often in the reference literature there is also a division of diabetic nephropathy into stages based on changes in the kidneys. Here are the stages of the disease:
- Hyperfiltration. At this time, the blood flow in the glomeruli accelerates (they are the main filter), the volume of urine increases, the organs themselves slightly increase in size. Lasts stage up to 5 years.
- Microalbuminuria. This is a slight increase in the level of albumin proteins in the urine (30-300 mg / day), which conventional laboratory methods are not yet able to ascertain. If these changes are diagnosed in time and treatment is organized, the stage can last for about 10 years.
- Proteinuria (macroalbuminuria in a different way). Here, the rate of filtration of blood through the kidneys decreases sharply, often renal arterial pressure (BP) jumps. The level of albumin in the urine at this stage can range from 200 to more than 2000 mg / day. This phase is diagnosed on the 10-15th year of the onset of the disease.
- Severe nephropathy. GFR decreases even more, the vessels are covered by sclerotic changes. Diagnosed 15-20 years after the first changes in the renal tissue.
- Chronic renal failure. Appears after 20-25 years of life with diabetes.
Diagram of the development of diabetic nephropathy
The first three stages of Mogensen pathology (or periods of hyperfiltration and microalbuminuria) are called preclinical. At this time, the external symptoms are completely absent, the volume of urine is normal. Only in some cases, patients may notice a periodic increase in pressure at the end of the microalbuminuria stage.
At this time, only special tests for the quantitative determination of albumin in the urine of a diabetic patient can diagnose the disease.
The stage of proteinuria already has specific external features:
- regular blood pressure surges,
- patients complain of swelling (face and legs first swell, then water accumulates in body cavities),
- weight drops sharply and appetite decreases (the body begins to spend protein stores to fill the shortage),
- severe weakness, drowsiness,
- thirst and nausea.
At the final stage of the disease, all of the above symptoms persist and increase. Edemas are getting stronger, droplets of blood are visible in the urine. Blood pressure in the renal vessels rises to patient-threatening numbers.
Diagnosis of diabetic kidney damage is based on two main indicators. This is the patient's history of diabetes patients (type of diabetes, how long the disease lasts, etc.) and indicators of laboratory research methods.
At the preclinical stage of development of vascular kidney damage, the main method is the quantitative determination of albumin in the urine. For the analysis, either the total urine volume per day, or morning (that is, the night portion) is taken.
Albumin indicators are classified as follows:
|Microalbuminuria||20–200 mg / min.||30-300||20-200 mg / l|
|Macroalbuminuria||> 200 mg / min.||> 300 mg||> 200 mg / l|
Another important diagnostic method is the identification of a functional renal reserve (increased GFR in response to external stimulation, for example, dopamine administration, protein loading, etc.). The rate is considered to increase the level of GFR by 10% after the procedure.
The rate of the GFR index itself is ≥90 ml / min / 1.73 m2. If this figure falls below, it indicates a decrease in kidney function.
Additional diagnostic procedures are also used:
- Reberg test (definition of SCF),
- general blood and urine analysis
- Ultrasound of the kidneys with Doppler (to determine the velocity of blood flow in the vessels),
- renal biopsy (for selected indications).
In the early stages, the main task in the treatment of diabetic nephropathy is to maintain an adequate level of glucose and to treat arterial hypertension. When the proteinuria stage develops, all treatment measures should be directed to slow down the decline in renal function and the appearance of CRF.
The following medications are used:
- ACE inhibitors - angiotensin converting enzyme, for pressure correction ("Enalapril", "Captopril", "Fozinopril", etc.),
- preparations for the correction of hyperlipidemia, that is, an increased level of fat in the blood ("Simvastatin" and other statins),
- diuretics ("Indapamide", "Furosemide"),
- iron preparations for the correction of anemia, etc.
A special low-protein diet is recommended already in the preclinical phase of diabetic nephropathy - in case of hyperfiltration of the kidneys and microalbuminuria.
During this period, you need to reduce the "portion" of animal proteins in the daily diet to 15-18% of the total calories. This is 1 g per 1 kg of the diabetic patient’s body weight. The daily amount of salt must also be dramatically reduced to 3-5 g.
It is important to limit fluid intake to reduce puffiness.
If the stage of proteinuria has developed, a special diet becomes a full-fledged therapeutic method. The diet turns into a low-protein - 0.7 g of protein per 1 kg. The amount of salt consumed should be reduced as much as possible, up to 2-2.5 g per day. This will prevent strong edema and reduce pressure.
In some cases, patients with diabetic nephropathy are prescribed ketone analogs of amino acids in order to exclude the body from splitting proteins from its own reserves.
Hemodialysis and peritoneal dialysis
Artificial cleansing of the blood by hemodialysis (“artificial kidney”) and dialysis is usually carried out in the late stages of nephropathy, when the native kidneys can no longer cope with filtration. Sometimes hemodialysis is prescribed at earlier stages, when diabetic nephropathy is already diagnosed, and organs need to be supported.
During hemodialysis, a catheter is inserted into the patient's vein, which is connected to a hemodialysis machine - a filtering device. And the whole system purifies the blood of toxins instead of the kidney within 4-5 hours.
The peritoneal dialysis procedure follows a similar pattern, but the cleaning catheter is not injected into the artery, but into the peritoneum. This method is used when hemodialysis is impossible for various reasons.
How often blood-purifying procedures are needed, only the doctor decides based on the tests and the patient's condition. If nephropathy has not yet been transferred to chronic renal failure, you can connect the "artificial kidney" once a week. When kidney function is running out, hemodialysis is done three times a week. Peritoneal dialysis can be done daily.
Artificial blood purification in nephropathy is necessary when the GFR falls to 15 ml / min / 1.73 m2 and an abnormally high level of potassium is recorded below (more than 6.5 mmol / l). And if there is a risk of pulmonary edema due to accumulated water, as well as there are all signs of protein-energy failure.
For diabetic patients, the prevention of nephropathy should include several main points:
- support of safe blood sugar levels in the blood (regulate physical exertion, avoid stress and constantly measure glucose levels),
- proper nutrition (a diet with a reduced percentage of proteins and carbohydrates, refusal from cigarettes and alcohol),
- control of the ratio of blood lipids,
- tracking blood pressure (if it jumps above 140/90 mm Hg, urgently need to take action).
All preventive measures must be agreed with your doctor. The therapeutic diet should also be carried out under the strict control of an endocrinologist and a nephrologist.
Diabetic Nephropathy and Diabetes
Treatment of diabetic nephropathy cannot be separated from the treatment of the cause - diabetes itself. These two processes should go in parallel and be adjusted in accordance with the results of analyzes of the patient-diabetic and the stage of the disease.
The main tasks in diabetes and kidney damage are the same - round-the-clock monitoring of glucose levels and blood pressure. The main non-drug means are the same at all stages of diabetes. These include weight control, healthy nutrition, reducing the amount of stress, avoiding bad habits, regular exercise.
The situation with taking medication is somewhat more complicated. In the early stages of diabetes and nephropathy, the main group of drugs is for pressure correction. Here it is necessary to choose drugs that are safe in patients with kidneys, approved for other complications of diabetes, and have at the same time cardioprotective and non-prophylactic properties. This is the majority of ACE inhibitors.
In insulin-dependent diabetes, ACE inhibitors are allowed to be replaced by angiotensin II receptor antagonists, if there are side effects from the first group of drugs.
When tests show proteinuria, in the treatment of diabetes it is necessary to take into account reduced kidney function and severe hypertension.
Special restrictions apply to diabetics with type 2 pathology: for them, the list of approved oral hypoglycemic agents (PSSS), which must be taken continuously, is sharply reduced.
Glikvidon, Gliclazid, Repaglinide remain the safest drugs. If GFR with nephropathy drops to 30 ml / min and lower, transfer of patients to insulin is necessary.
There are also special drug regimens for diabetics depending on the stage of nephropathy, albumin, creatinine and GFR.
So, if creatinindo increases to 300 µmol / l, the dosage of the ATP inhibitor is halved, if it jumps higher, and completely canceled - before hemodialysis.
In addition, in modern medicine, there is a non-stop search for new drugs and therapeutic regimens that allow simultaneous treatment of diabetes and diabetic nephropathy with minimal complications.
In the video about the causes, symptoms and treatment of diabetic nephropathy:
Kidney damage in diabetes mellitus: treatment of proteinuria
In diabetes, insulin production is impaired or tissue resistance to it develops. Glucose can not get into the organs and circulates in the blood.
Lack of glucose, as one of the energetic materials, leads to disruption of the organs and systems in the body, and its excess in the blood damages blood vessels, nerve fibers, liver and kidneys.
Kidney damage in diabetes mellitus is the highest level of dangerous complications, their insufficiency of function leads to the need for hemodialysis and kidney transplantation. Only this can save the lives of the sick.
How are kidneys damaged in diabetics?
Purification of blood from waste occurs through a special renal filter.
Its role is performed by the glomeruli.
The blood from the vessels around the glomeruli passes under pressure.
Most of the fluid and nutrients are returned, and metabolic products through the ureters and the bladder is expelled.
In addition to cleansing the blood, the kidneys perform the following vital functions:
- Development of erythropoietin, affecting blood formation.
- Synthesis of renin, which regulates blood pressure.
- Regulation of calcium and phosphorus metabolism, which are included in the structure of bone tissue.
Blood glucose causes glycation of proteins. To them in the body begin to produce antibodies. In addition, with such reactions, the level of platelets in the blood rises and small blood clots are formed.
Proteins in glycated form can leak through the kidneys, and increased pressure accelerates this process. Proteins accumulate on the walls of capillaries and between them in the kidney tissue. All this affects the capillary permeability.
In the blood of diabetics there is an excess of glucose, which, passing through the glomerulus, takes with it a lot of fluid. This increases the pressure inside the glomerulus. Growing glomerular filtration rate. At the initial stage of diabetes, it increases and then begins to fall gradually.
In the future, due to the constant increased load on the kidneys with diabetes mellitus, some of the glomeruli do not withstand overloads and die. Over time, this leads to a decrease in blood clearance and the development of symptoms of renal failure.
The kidneys have a large supply of glomeruli, so this process is quite slow, and the first symptoms of kidney impairment in diabetes are usually detected no earlier than five years after the onset of the disease. These include:
- General weakness, shortness of breath with the slightest exertion.
- Lethargy and drowsiness.
- Persistent swelling of the legs and under the eyes.
- High blood pressure.
- Drop in blood sugar.
- Nausea, vomiting.
- Unstable chair with alternating constipation and diarrhea.
- The calf muscles hurt, cramps in the legs, especially in the evening.
- Itching of the skin.
- The taste of metal in the mouth.
- There may be urine smell from the mouth.
The skin becomes pale, with a yellowish or sallow shade.
Laboratory diagnosis of kidney damage
Determination of glomerular filtration rate (Reberg test). To determine the volume of urine, which stood out per minute, collect daily urine. You must know exactly the time during which the collection of urine. Then according to the formulas calculate the filtration rate.
The normal rate of kidney function is more than 90 ml per minute, up to 60 ml - the function is slightly impaired, and up to 30 - moderate kidney damage. If the speed drops to 15, then a diagnosis of chronic renal failure is made.
Urine analysis for albumin. Albumin has the smallest size among all urine excreted proteins. Therefore, the detection of microalbuminuria in the urine means that the kidneys are damaged. Albuminuria develops with nephropathy in patients with diabetes mellitus, it also manifests itself with the threat of myocardial infarction and stroke.
The amount of albumin in urine is up to 20 mg / l, up to 200 mg / l is diagnosed with microalbuminuria, above 200 - macroalbuminuria and severe kidney damage.
In addition, albuminuria may appear with congenital glucose intolerance, autoimmune diseases, hypertension. It can cause inflammation, a stone in the kidney, cysts, chronic glomerulonephritis.
To determine the extent of kidney damage in diabetes, you need to conduct a study:
- Biochemical analysis of blood for creatinine.
- Determination of glomerular filtration rate.
- Urine analysis for albumin.
- Creatinine urine test.
- Blood test for creatinine. The final product of protein metabolism is creatinine. Creatinine levels may increase with a decrease in kidney function and insufficient blood clearance. Coma renal pathology creatinine may increase with intense physical exertion, the prevalence of meat food in the diet, dehydration, taking medications that damage the kidneys.
Normal values for women are from 53 to 106 µmol / l, for men from 71 to 115 µmol / l.
4. Creatinine urine analysis. Creatinine from the blood is excreted by the kidneys. In case of a malfunction of the kidneys, with considerable physical exertion, infections, nutrition, mainly meat products, endocrine diseases, the level of creatinine increases.
The norm in mmol per day for women is 5.3 -15.9, for men 7.1 - 17.7.
Evaluation of the data from these studies makes it possible to make predictions: how likely is the kidney failure and at what stage is chronic kidney disease (CCP)? Such a diagnosis is also necessary because the pronounced clinical symptoms begin to appear at the stage when changes in the kidneys are irreversible.
Albuminuria appears at the initial stage, therefore, if treatment is started, chronic renal failure can be prevented.
Treatment of kidney diabetes
They are most effectively treated with diabetes mellitus. The kidneys at the stage when albuminuria appeared not exceeding 200 mg / l.
The main method of treatment is to compensate for diabetes, maintaining the recommended level of glycemia. In addition, drugs are assigned from the group of angiotensin-converting enzymes. Their purpose is shown even at a normal pressure level.
Taking small doses of such drugs can reduce the protein in the urine, prevent the destruction of the renal glomeruli. Usually the attending physician prescribes these drugs:
The proteinuria stage requires the restriction of animal protein in the diet. This does not apply to children and pregnant women. Everyone else is encouraged to abandon meat products, fish, cottage cheese and cheese.
With high blood pressure, you should avoid salty foods, it is recommended to use no more than 3 grams of salt per day. To add flavor, you can use lemon juice and herbs.
To reduce the pressure at this stage usually use drugs:
In the case of resistance, diuretics are connected to them or a combination drug is used.
If diabetes mellitus and kidneys are not treated for a long time, then this leads to the development of chronic renal failure. Over time, the glomerular kidney tissue becomes small and the kidneys begin to fail.
This condition requires repeated monitoring of the sugar level throughout the day, since, in compensating for diabetes, it is possible to prevent the development of comatose states and infections that often accompany diabetes at this stage.
If the pills do not give effect, transfer such patients to insulin therapy. With a sharp drop in sugar levels, urgent resuscitation is required in the clinic.
Diabetic nephropathy at the stage of chronic renal failure requires changes in diet. The usual restriction of simple carbohydrates at this stage is not beneficial. Additionally, the following rules are introduced in the diet:
- At this stage, animal proteins are limited or completely excluded.
- In addition, there is a risk of increased potassium in the blood. Foods high in potassium are excluded from the diet: potatoes, raisins, prunes, dried apricots, dates and black currants.
- In the diet it is also required to limit foods with a high content of phosphorus (fish, cheese, buckwheat), to introduce calcium from fermented milk drinks, sesame, and celery into the menu.
An important condition at the stage of renal failure is to control pressure and excretion of potassium with the help of diuretic drugs - Furosemide, Uregit. The control over the drunk and deduced water, decrease in hypostases is obligatory.
Anemia with kidney damage requires prescription of erythropoietin and iron supplements. To bind toxins in the intestines, sorbents are used: Enterodez, activated carbon, Polysorb.
With further progression of renal failure, patients are connected to a blood purifier. The indication for dialysis is the level of creatinine above 600 µmol / l. Such sessions are conducted under the control of biochemical parameters and are the only way to support vital activity.
Hemodialysis or peritoneal dialysis procedures are performed. And in the future, such patients are shown kidney transplantation, which will be able to restore the working capacity and activity of patients.
The video in this article continues the topic of kidney disease in diabetes.
Pathological anatomy of glomerusclerosis
The following morphological forms of glomerusklerosis are distinguished:
- nodular form is expressed in the formation of sclerotic oval nodules in the renal glomeruli and is more often observed in diabetes mellitus type I. Nodules can occupy most of the renal glomeruli, causing the appearance of aneurysms and pathological thickenings in the tissues of the surrounding basal membranes,
- diffuse form of the disease is expressed in a uniform thickening of the tissues of the glomeruli and membranes without the formation of nodules,
- exudative form is accompanied by the formation of round formations on the surface of the glomerular capillaries.
In some cases, the simultaneous development of nodular and diffuse forms of renal pathology is possible.
During the development of diabetes mellitus, kidney damage progresses, degenerative changes occur in the epithelium, the basement membranes accumulate paraproteids and become hyaline-like, and the tissues are replaced by connective and fatty.
As a result of diabetic nephropathy, the glomeruli die, the kidneys lose their functionality, and periglomerular fibrosis develops, and then renal failure.
Symptoms of the disease
In diabetes mellitus, all pathological changes in the kidneys develop against the background of filtration of blood with a high sugar content - the main damaging factor. Excess glucose has a direct toxic effect on the tissues of the organ, reducing their filtration capacity.
Due to an increase in membrane permeability, protein (albumin), which, with its natural functionality, remains in the blood, enters the urine. The presence of an increased amount of albumin in the urine is one of the main diagnostic criteria for diabetic nephropathy.
Characteristic signs of kidney disease include:
- proteinuria - detection of protein in urine analysis,
- retinopathy - damage to the eye retina,
- hypertension - high blood pressure.
The combination of these symptoms of kidney disease in diabetes increases their severity, therefore, serves as a criterion for diagnosing the disease.
In the initial stage of the development of the disease, kidney damage is asymptomatic. To avoid possible complications, doctors recommend to undergo an annual examination of all patients with diabetes. The analysis of blood and urine for creatinine, the calculation of the glomerular filtration rate, and the urine analysis for albumin are considered mandatory.
Patients who, due to genetic predisposition, are at risk, should pay attention to the totality of symptoms characteristic of diabetes and glomeruskleroza:
- increase in the amount of urine (polyuria),
- lethargy, weakness, shortness of breath,
- itching, skin infections,
- high blood pressure
- appearance of metal taste in the mouth,
- increased thirst
- frequent leg cramps
- weight loss for no apparent reason
- slow wound healing
- diarrhea, nausea or vomiting,
- infections of the genitourinary system
- loss of consciousness.
Timely medical examination is the only way to not miss the onset of diabetic kidney damage and prevent the development of irreversible changes in the body.
Stages and clinical manifestations
In diabetes, kidney damage develops in stages:
- the initial stage passes without visible signs of the disease. Higher glomerular filtration rate and intensity of renal blood flow may indicate primary kidney damage,
- pronounced clinical manifestations of glomeruskleroz are observed during the transition stage. The structure of the renal glomeruli gradually changes, thickening the walls of the capillaries. Microalbumin is still in the normal range. the intensity of blood flow and the filtration rate of the blood is maintained at a high level,
- for the pre-nephrotic stage of kidney damage due to diabetes is characterized by an increase in albumin levels. There is a periodic increase in blood pressure
- in the nephrotic stage, all characteristic signs of kidney pathology are observed — proteinuria, a decrease in the renal blood flow and filtration rate of the blood, and a persistent increase in blood pressure. Indicators of creatinine in the blood slightly increased. Blood tests show an increase in indicators - ESR, cholesterol, etc. Blood may appear in urine tests,
- The final stage of development of diabetic pathology of the kidney is considered nephrosclerotic stage (uremic). It is characterized by a sharp decrease in the functionality of the kidneys, an increase in the amount of urea and creatinine in blood tests against the background of a decrease in protein indicators. Observed blood and protein in the urine, develops severe anemia. The degree of increase in blood pressure reaches the limit values. Blood glucose levels may decrease.
The last stage of development of complications in diabetes mellitus is regarded as irreversible and leads to chronic renal failure, in which the body is maintained by blood purification using dialysis or using a kidney transplant operation.
How does diabetes mellitus affect the kidneys?
Changes in the kidneys in diabetes mellitus begin to seal the walls.
In the body there are glomeruli that filter the fluid in the human body. Due to the compaction of the walls of the organ, these glomeruli become smaller (they lose capillaries), pathology leads to the fact that they can no longer cleanse the body. The body does not remove the necessary amount of liquid waste from the body, and the blood becomes less.
Renal diabetes contributes to the fact that other organs are affected. Often the disease passes without symptoms. This is due to the fact that in the human body there are other nodules that cleanse the blood. When they perform their functions, the first symptoms appear in a person, but the state of the organ is already poor.
Therefore, it is necessary to conduct a planned diagnosis of diseases of this organ.
Causes of kidney disease in diabetes
The main reason for the failure of an organ is a lot of sugar in the blood, but, in addition, such factors also affect them:
- eating fast food
- increased blood pressure.
There are 3 types of organ pathology. They are discussed in the table:
|Angiopathy||The organ suffers from oxygen deprivation (organ ischemia)|
|Against this background, marked hypertension|
|Diabetic Nephropathy||The body is not able to filter the liquid due to changes in the vessels|
|Diagnosed through fundus examination|
|Chronic urinary tract infection||The increase in sugar in urine contributes to the active development of pathogenic microorganisms|
Symptoms of pathology
Edema as a symptom of kidney problems.
Disorders of the kidneys can be identified by the following symptoms:
- increased blood pressure
- swelling (daytime legs, night face and hands),
- red color of urine
- frequent urination with itching and burning,
- back pain,
- itching of the skin without rash.
Blood in the urine in diabetes mellitus suggests that there are chronic kidney disease (CKD). Other clinical features include:
- Leukocytes in the urine. Nephritis is diagnosed that way.
- Red blood cells. In combination with protein in urine, red blood cells help diagnose glomerulonephritis,
- Protein in the urine.
Diagnosis of the disease
CKD can be diagnosed using the methods:
- Clinical analysis of urine. Diagnosed with albuminuria (the appearance in the urine of albumin, blood proteins).
- Excretory urography. X-ray of the kidney with the introduction of a contrast agent, allows to estimate the size and location of the organ and urinary tract.
- Ultrasound of the kidneys. Appointed with kidney stones, cysts are diagnosed.
- Needle biopsy of the kidney. Part of the organ is taken for analysis and examined for the presence of pathological changes.
- Computed tomography (CT). Evaluates the condition of the vessels, the presence of tumors and stones.
Treatment of the disease
The treatment is prescribed by a doctor, one of the drugs included in the treatment complex is Captopril.
Treatment of kidney diabetes is complicated by the fact that many drugs are contraindicated. ACE inhibitors ("Benazepril", "Captopril", "Enalapril") are those drugs that are allowed in the treatment of this disease. They lower blood pressure and normalize the amount of albumin in the blood. They will not cure diabetes, but they will reduce the probability of death from diseases of the organ by 50%.
Because of these drugs, an imbalance of minerals (phosphorus, potassium) occurs, which leads to other diseases of the organ and heart. ACE inhibitors are not used and are assigned angiotensin 2 receptor blockers ("Losartan", "Valsartan"). If the pills are not able to help, and complications also develop, then dialysis is prescribed (artificial cleaning of the kidneys) or transplanting a diseased organ.
There are 2 types of dialysis:
- Peritoneal. A lot of liquid preparation is injected through the catheter into the abdominal cavity. It destroys toxins and removes all that is bad in the body. It is carried out 1 time per day throughout the patient's life (or before the transplant).
- Hemodialysis. This method is also called "artificial kidney". A tube is inserted into the person’s artery, which pumps blood, the filter cleans it and reintroduces it to the person. This method leads to a strong decrease in blood pressure and has a high risk of infection.
If the organs failed or refuse, then do not waste time: the drugs will no longer help. Treatment of kidney diabetes becomes ineffective.
A kidney transplant is the only way to prolong a person’s life and normalize it for a long time.
But the operation has its drawbacks: the body can not settle down, the high cost of the operation, diabetic influence destroys the new body, drugs that weaken the immune system, lead to a worsening of diabetes.
At the first kidney problems, a diabetic should consult a doctor to prevent negative consequences.
Changes in the kidneys in diabetes contribute to the emergence of a large number of complications. The disease progresses rapidly and leads to the following consequences:
- retinopathy (the fundus vessels are deformed),
- neuropathy (nervous system disorder),
- chronic urinary tract infection,
- renal failure.
Diabetic crisis leads to the fact that the pathology of the kidneys develop. Damage to the kidneys of a diabetic leads to the deterioration of his condition. Symptoms include:
- sore kidneys
- high body temperature (inflammation of the kidneys),
Nephrotic syndrome in diabetes mellitus
Diabetic nephropathy is a serious damage to the kidneys, expressed in a decrease in the functional ability of the organs. Pathological syndrome develops due to the influence of various factors that are the companions of diabetes. The causes of development and the possible consequences of nephrotic syndrome in diabetes mellitus will be discussed further.
Causes of nephrotic syndrome.
Diabetic nephropathy progresses rather slowly, the intensity of the manifestation of symptoms depends largely on the functioning of the internal organs and the intensity of the pathological changes present.
There are several stages in the development of such a disorder:
- terminal stage of chronic renal failure.
For a long time, pathological progress is asymptomatic. At the initial stage, there is a slight increase in the size of the glomeruli of the kidneys, the renal blood flow increases and the glomerular filtration rate increases.
Edema in nephrotic syndrome.
Attention! The initial structural changes in the glomerular apparatus of the kidneys can be traced several years after the start of the disease.
Clinically severe diabetic nephropathy in type 1 diabetes mellitus can be traced after 15–20 years, it is characterized by persistent proteinuria. Glomerular filtration rate and renal blood flow is difficult to correct. The level of creatinine in the urine remains normal or does not increase significantly.
At the terminal stage, there is a sharp decrease in the filtration and concentration functions of the kidneys. Traced massive proteinuria and low glomerular filtration rate.
The nephrotic syndrome progresses, and the blood pressure of patients often increases rapidly. The development of dyspeptic syndrome, uremia and chronic renal failure is not excluded, subject to the manifestation of signs of poisoning of the human body by products of toxic decomposition.
Treatment should be under the supervision of a specialist.
Modern medicine identifies 5 stages, alternately alternating with diabetic nephropathy. This process can be adjusted. If the treatment is started promptly, the dynamics of the pathology is absent.
|Stages of diabetic nephropathy|
|Kidney hyperfunction||External signs are not traced, an increase in the size of the vascular cells of the kidneys can be determined. The process of filtering and excretion of urine is activated. There is no protein in the urine.|
|Initial structural changes||Manifested 2 years after the detection of diabetes in a patient. There are no symptoms of diabetic nephropathy. There is a thickening of the vascular cells of the kidneys, protein in the urine is absent.|
|Incipient diabetic nephropathy||It occurs after 5 years and it is at this stage that the pathological process can be identified during a routine inspection. The concentration of protein in the urine is about 300 mg per day. This phenomenon indicates minor damage to the renal vessels.|
|Severe diabetic nephropathy||The pathological process has a pronounced clinical picture and develops approximately 12-15 years after the onset of diabetes mellitus. Characteristically, urine protein excretion in sufficient volumes, proteinuria. In the blood, protein concentration decreases, edemas occur. At an early stage, edema is localized on the lower limbs and on the face. As the pathology progresses, fluid accumulates in various body cavities, thoracic, abdominal, pericardial - swelling spreads. In severe kidney damage, diuretic drugs are indicated. A treatment option is surgery, at this stage the patient needs puncture. Prescribing diuretic drugs will not provide an effective result.|
|The end of diabetic nephropathy, end-stage disease||Traced absolute stenosis of the renal vessels. Significantly reduced filtration rate, excretory function of the kidneys is not provided the necessary way. There is a clear threat to the life of the patient.|
The first three stages can be considered as preclinical. With them, patients do not express any complaints about the manifestation of individual symptoms.
Kidney damage can only be determined if any special laboratory tests and microscopy of the kidney tissues are performed. It is very important to identify the pathological process in the early stages. Because in advanced cases, adequate treatment is impossible.
This article will introduce readers to the main risks of kidney disease in diabetics.
Features of treatment
Blood sugar levels must be constantly monitored.
The instructions for the treatment and prevention of diabetic nephropathy are as follows:
Attention! The survey found that hyperglycemia is the main trigger factor for the appearance of structural and functional changes in the kidneys.
Studies have confirmed that continuous glycemic control leads to a marked reduction in the frequency of microalbuminuria and albuminuria in people with diabetes. No less important is the control of blood pressure, it is necessary for the prevention of nephropathy and a significant reduction in the rate of its progress.
When detecting arterial hypertension, a diabetic should observe the following rules:
- refusing to eat salt,
- increase physical activity
- restoration of normal body weight
- refusal to drink alcohol,
- nicotine addiction rejection
- decrease in saturated fat intake,
- reduction of mental stress.
Choosing antihypertensive drugs for people with diabetes mellitus, you should stop paying attention to the effect of such drugs on carbohydrate and lipid metabolism. Such drugs should have a minimal risk of adverse reactions in patients during administration of the drug.
In diabetes mellitus, the following drugs are more commonly used to lower blood pressure:
- Captopril (pictured)
These drugs are made in the form of tablets intended for oral administration. The instructions governing the process of use for patients with diabetes mellitus are determined by the attending physician individually.
The vast majority of patients with diabetic nephropathy grade 4 and above have dyslipidemia. Correction is necessary when detecting lipid metabolism disorders. At the initial stage, the hypolipidemic diet is imputed. In advanced cases, they resort to taking lipid-lowering drugs.
If the concentration of low density lipoproteins in the blood of a patient with diabetes is higher than 3 mmol / l, statins are taken.
In medical practice, most commonly used:
With isolated hypertriglyceridemia, fibrates are administered, namely Fenofibrate or Cyprofibrate. Contraindication for their purpose is to change the GFR.
Features of the treatment of nephrotic syndrome in diabetics.
At the microalbuminuria stage, recovery can be achieved provided that the amount of animal protein intake is reduced.
Refusing to consume salt.
At the early stage of diabetic kidney damage, the result of the restoration of organ function depends largely on the compliance of patients with basic norms of proper nutrition. Often, patients are recommended to limit the amount of protein intake, the weight consumed should be no more than 12–15% of the total caloric intake.
When symptoms of hypertension are manifested, the amount of salt intake should be reduced to 3-4 grams per day. The total caloric intake per day for men should be 2500 kcal, for women - 2000 kcal.
In diabetic nephropathy at the stage of proteinuria, the diet is the best method of symptomatic therapy. The amount of salt intake should be reduced to the very minimum. Flavoring does not make the dishes, it is also preferred to salt-free baking.
Diet as a method of treatment.
Microalbuminuria is the only reversible stage of diabetic nephropathy, subject to quality treatment. At the proteinuria stage, the best outcome is to prevent the progress of the disease to chronic renal failure.
Diabetic nephropathy and chronic renal failure resulting from it is a powerful indication for hemodialysis. Also a valid treatment option is a kidney transplant.
The terminal stage indicates the development of a state incompatible with life. Chronic renal failure that develops in type 1 diabetes mellitus is a common cause of death in patients younger than 50 years of age.
Prevention of the development of nephrotic syndrome in diabetes mellitus consists in regular visits by the patient to an endocrinologist. The patient should be aware of the need to constantly monitor the concentration of sugar in the blood and follow the advice prescribed by a specialist. The cost of not complying with such recommendations is often too high for the patient.
Causes of Diabetic Nephropathy
Diabetic nephropathy is due to pathological changes in the renal vessels and glomeruli of capillary loops (glomeruli), which perform a filtration function.
Despite the different theories of the pathogenesis of diabetic nephropathy, considered in endocrinology, hyperglycemia is the main factor and starting element of its development.
Diabetic nephropathy occurs due to prolonged insufficient compensation of carbohydrate metabolism disorders.
According to the metabolic theory of diabetic nephropathy, persistent hyperglycemia gradually leads to changes in biochemical processes: non-enzymatic glycosylation of protein molecules of the renal glomeruli and a decrease in their functional activity, impaired water-electrolyte homeostasis, fatty acid metabolism, reduction of oxygen transport, activation of the polyol pathway of glucose utilization and toxic effect on kidney tissue, increased renal vascular permeability.
Hemodynamic theory in the development of diabetic nephropathy plays a major role in arterial hypertension and impaired intrarenal blood flow: an imbalance of tone that brings in and out arterioles and an increase in blood pressure inside the glomeruli.
Prolonged hypertension leads to structural changes in the glomeruli: first to hyperfiltration with accelerated formation of primary urine and the release of proteins, then to replacement of the tissue of the renal glomerulus with connective (glomerulosclerosis) with complete occlusion of the glomeruli, reduction in their filtration capacity and the development of chronic renal failure.
Genetic theory is based on the presence of genetically determined predisposing factors in a patient with diabetic nephropathy, manifested in metabolic and hemodynamic disorders. In the pathogenesis of diabetic nephropathy are involved and closely interact with each other all three mechanisms of development.
Risk factors for diabetic nephropathy are arterial hypertension, prolonged uncontrolled hyperglycemia, urinary tract infections, disorders of fat metabolism and overweight, male gender, smoking, use of nephrotoxic drugs.
Diabetic nephropathy is a slowly progressive disease, its clinical picture depends on the stage of pathological changes. In the development of diabetic nephropathy, stages of microalbuminuria, proteinuria and the terminal stage of chronic renal failure are distinguished.
For a long time, diabetic nephropathy is asymptomatic, without any external manifestations.
At the initial stage of diabetic nephropathy, there is an increase in the size of the glomeruli of the kidneys (hyperfunctional hypertrophy), increased renal blood flow and an increase in glomerular filtration rate (GFR).
A few years after the debut of diabetes mellitus, the initial structural changes in the glomerular apparatus of the kidneys are observed. A high volume of glomerular filtration is maintained, urinary albumin excretion does not exceed normal values (
Diabetic nephropathy begins to develop more than 5 years after the onset of the pathology and is manifested by persistent microalbuminuria (> 30-300 mg / day or 20-200 mg / ml in the morning urine).
There may be a periodic increase in blood pressure, especially during exercise.
Deterioration of health of patients with diabetic nephropathy is observed only in the later stages of the disease.
Clinically severe diabetic nephropathy develops after 15–20 years with type 1 diabetes mellitus and is characterized by persistent proteinuria (urine protein level is> 300 mg / day), indicating irreversibility of the lesion.
Renal blood flow and SKF decrease, arterial hypertension becomes permanent and difficult to correct. Nephrotic syndrome develops, manifested by hypoalbuminemia, hypercholesterolemia, peripheral and abdominal edema.
Creatinine and blood urea levels are normal or slightly elevated.
At the terminal stage of diabetic nephropathy, there is a sharp decrease in the filtration and concentration functions of the kidneys: massive proteinuria, low GFR, a significant increase in the level of urea and creatinine in the blood, the development of anemia, and marked edema.
At this stage, hyperglycemia, glycosuria, urinary excretion of endogenous insulin, and the need for exogenous insulin can significantly decrease.
Nephrotic syndrome progresses, blood pressure reaches high values, dyspeptic syndrome, uremia and chronic kidney disease develops with signs of self-poisoning of the body with metabolic products and damage to various organs and systems.
Early diagnosis of diabetic nephropathy is a major challenge.In order to establish the diagnosis of diabetic nephropathy, a biochemical and complete blood count, a biochemical and complete urinalysis, a Reberg test, a Zimnitsky test, a USDG of the kidney vessels are carried out.
The main markers of the early stages of diabetic nephropathy are microalbuminuria and glomerular filtration rate. When annual screening of patients with diabetes mellitus, examine the daily excretion of albumin in the urine or the ratio of albumin / creatinine in the morning portion.
The transition of diabetic nephropathy to the stage of proteinuria is determined by the presence of protein in the general urine analysis or albumin excretion in the urine above 300 mg / day. There is an increase in blood pressure, signs of nephrotic syndrome.
Late stage of diabetic nephropathy is not difficult to diagnose: to massive proteinuria and reduce GFR (less than 30 - 15 ml / min), added to the increase in levels of creatinine and urea in the blood (azotemia), anemia, acidosis, hypocalcemia, hyperphosphatemia, hyperlipidemia, swelling of the face and the whole body.
It is important to carry out a differential diagnosis of diabetic nephropathy with other kidney diseases: chronic pyelonephritis, tuberculosis, acute and chronic glomerulonephritis.
For this purpose, bacteriological examination of the urine on the microflora, ultrasound of the kidneys, and excretory urography can be performed.
In some cases (with early developed and rapidly increasing proteinuria, the sudden development of nephrotic syndrome, persistent hematuria), a fine-needle aspiration biopsy of the kidney is performed to clarify the diagnosis.
Treatment of diabetic nephropathy
The main goal of treating diabetic nephropathy is to prevent and further delay the further progression of the disease to CRF, reduce the risk of developing cardiovascular complications (IHD, myocardial infarction, stroke). Common in the treatment of different stages of diabetic nephropathy is strict control of blood sugar, blood pressure, compensation for violations of mineral, carbohydrate, protein and lipid metabolism.
The drugs of first choice in the treatment of diabetic nephropathy are angiotensin-converting enzyme (ACE) inhibitors: enalapril, ramipril, tradolapril and angiotensin receptor antagonists (ARA): irbesartan, valsartan, losartan, normalizing a system and an intrageneraminon receptor antagonists: irbesartan, valsartan, losartan, normalizing a system and an intrageneraminon receptor antagonist: irbesartan, valsartan, losartan, normalizing a system and an intrageneral receptor antagonist: irbesartan, valsartan, losartan, normalizing a system with an angiotensin receptor (ARA): Drugs are prescribed even with normal blood pressure in doses that do not lead to the development of hypotension.
Starting from the microalbuminuria stage, a low protein, salt-free diet is shown: restriction of the intake of animal protein, potassium, phosphorus, and salt. To reduce the risk of developing cardiovascular diseases, dyslipidemia correction is necessary due to a low-fat diet and taking drugs that normalize the blood lipid spectrum (L-arginine, folic acid, statins).
At the terminal stage of diabetic nephropathy, detoxification therapy, correction of diabetes treatment, administration of sorbents, anti-azothemic agents, normalization of hemoglobin level, prevention of osteodystrophy are required. With a sharp deterioration in renal function, the question is raised about the patient's hemodialysis, permanent peritoneal dialysis, or surgical treatment with a donor kidney transplant.
Prognosis and prevention of diabetic nephropathy
Microalbuminuria with timely prescribed adequate treatment is the only reversible stage of diabetic nephropathy. At the stage of proteinuria, it is possible to prevent the progression of the disease to CRF, while reaching the terminal stage of diabetic nephropathy leads to a state incompatible with life.
Currently, diabetic nephropathy and the developing chronic renal failure are the leading indications for replacement therapy - hemodialysis or kidney transplantation. CKD due to diabetic nephropathy causes 15% of all deaths among patients with type 1 diabetes younger than 50 years.
Prevention of diabetic nephropathy is the systematic observation of patients with diabetes mellitus at the endocrinologist diabetologist, timely correction of therapy, constant self-monitoring of blood glucose levels, compliance with the recommendations of the attending physician.