Diabetic Nephropathy

diabetic nephropathy, also known as Kimmelstiel-Wilson disease or diabetic glomerulosclerosis, deterioration of kidney function occurring as a complication of diabetes mellitus. The condition is characterized primarily by increased urinary excretion of the protein albumin, increased blood pressure, and reduced glomerular filtration rate (the average rate at which wastes are filtered out of the blood plasma by the kidneys). Diabetic nephropathy is a leading cause of end-stage renal disease (ESRD), which is characterized by kidney failure, with the organ’s function reduced to less than one-tenth of normal capacity or lost completely.

Diabetic nephropathy generally manifests within 10 to 20 years of diabetes onset and affects roughly 20 to 40 percent of persons diagnosed with type I diabetes and 5 to 20 percent of those with type II diabetes. The disorder appears to cluster in families, particularly in those in which there exists a history of type I diabetes. This suggests that genetic factors might leave some diabetic individuals more susceptible to nephropathy than others. However, the underlying cause of the condition is unclear. A host of chronic pathological changes characteristic of diabetes have been implicated, including chronic high blood sugar (hyperglycemia), particularly when combined with high blood pressure (hypertension). Persistence of both conditions can result in damage to the functional units of the kidneys—the nephrons, which produce urine through the process of filtration (the removal of wastes from the blood for urinary excretion).

There are five clinical stages of diabetic nephropathy. Progression from one stage to the next is determined by clinical measurements of blood pressure, urinary excretion of albumin, and glomerular filtration rate. The first stage, hyperfiltration, generally is considered to be an indication that the diabetic patient is at increased risk for nephropathy. Hyperfiltration is followed by normoalbuminuria, in which albumin excretion and blood pressure are normal but detectable glomerular lesions are present. The third stage, microalbuminuria, is characterized by elevations in blood pressure and urinary excretion of albumin and stable or decreasing glomerular filtration rate. Microalbuminuria generally appears 5 to 15 years following diabetes diagnosis. Stage four is known as overt albuminuria and is characterized by elevated urinary excretion of albumin (greater than 300 mg/ml, or more than 10 times normal), decreased glomerular filtration, and, in many patients, hypertension. Stage five, ESRD, ensues when the glomerular filtration rate drops below 15 ml per minute (the normal rate is 75–115 ml per minute for women and 85–125 ml per minute for men).

Treatment for diabetic nephropathy is focused primarily on the reduction of blood glucose levels and blood pressure. Although in many diabetic patients these factors can be controlled largely through diet and exercise, pharmacological interventions often are needed to prevent or delay the progression of diabetic nephropathy and to control the condition in severe cases. Pharmacological approaches to blood glucose management include the administration of insulin, which promotes the uptake of glucose from the blood by tissues such as muscle, and the use of oral hypoglycemic (blood glucose-lowering) medications, including sulfonylureas and thiazolidinediones. These medications help limit the damage inflicted on renal blood vessels by harmful substances known as advanced glycation end products (AGEs), which are formed from the union in the blood of glucose and the red blood cell component hemoglobin. Antihypertensive (blood pressure-lowering) drugs used to delay the advance of diabetic nephropathy include angiotensin-converting enzyme (ACE) inhibitors.