Fek - 5-5 - Diabetic Nephropathy

Front 1

most common cause of dialysis

Back 1

diabetic nephropathy

Front 2

Causes of disability in diabetes

Back 2

blindness, ESRD, CHD, stroke, amputation

Front 3

Early stage of diabetic nephropathy will see...

Back 3

renal and glomerular hypertrophy with hyperfiltration (GFR goes up)

Front 4

Established stage of diabetic nephropathy will see....

Back 4

GBM thickening, mesangial matrix expansion and increased albumin excretion rate.

Front 5

Advanced stage of diab nephropathy will se...

Back 5

nodular glomerulosclerosis, arteriolar hyalinosis, interstitial matrix expansion, HTN, proteinuria, decreased renal function, tubulointerstitial fibrosis.

macroalbuminuria.

Front 6

Main things seen with kidney in diab neph

Back 6

Microalbuminuria (>30 creatinine) or clinical albuminuria (>300 creatinine)

HTN

dec GFR

Front 7

Ang II role in pathogenesis of renal disease

Back 7

Causes increased BP and constriction of efferent arteriole to cause glomerular HTN and proteinuria/focal segmental glomerulosclerosis.

It also increases sodium abs at prox tubule.

This all leads to more TGF-beta (and thus more ECM, interstitial fibrosis, and focal segmental glomerulosclerosis to knock of glomeruli one by one).

Front 8

Eye findings

Back 8

hemorrhage and ischemia spots in the eye.

Front 9

Histo changes in t2dm

Back 9

kimmelstein-wilson nodules in the setting of diffuse nodular glomerulosclerosis.

thickening of the basement membrane.

Front 10

if prot is negative on urinalysis...

Back 10

still might have microalbuminuria.

do a random, spot urine for albuminuria.

20-200 ug/min is diabetic nephropathy

Front 11

cutoff for microalbuminuria vs clinical

Back 11

micro - 30-299 a day
clinical - >=300

Front 12

management of diabetic nephropathy

Back 12

Control hyperglycemia, HbA1C <7%

Exercise

Quit smoking

<130/80

Use ACEIs or ARBs, diuretics, and calcium antagonists (Verapamil or Diltiazem) to slow progression
(specifically said not to use amlodipine though...)

Restrict sodium intake (Dash diet) and possibly protein intake

Treat lipids aggressively (HMG CoA reductase inhibitors)

Front 13

Primary prevention

Back 13

good glycemic control and avoid HTN

Front 14

Secondary prevention

Back 14

strict strict strict glycemic control, ACE inhibition, anti-HTN treatment.

Front 15

isue with A1c

Back 15

and improvement is better than nothing, even if not under 7%

Front 16

big hips are...

Back 16

protective against bad CV complications.

waist to hip is more accurate than BMI

Front 17

diff btwn t1 and t2 diabetic HTN

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1 - mainly caused by nephropathy. manifests with microalbuminuria.

2 - present in 1/3 of dx. coexists with numerous other CV comorbidities.

Front 18

first line HTN control

Back 18

ACE or ARBs.

second line is addition of diuretic.

Front 19

renal disease progression

Back 19

microalbuminuria --> overt proteinuria --> doubling of creatinine --> ESRD

(most pts die of CV events before creatinine has a chance to double)

Front 20

why is microalbuminuria important?

Back 20

signifies small vessel disease i nkidney and heart.

40% progress to overt proteinuria.

Front 21

how to tx proteinuria

Back 21

1. ace inh (achieves similar BP control compared to other drugs and also leads to less proteinuria and thus progression to kidney disease)

2. ARBs - same rationale as ace

2.5. Thiazides

3. spironolactone (NOT IN PTS WITH HIGH CREATININE - CAN CAUSE HYPERKALEMIA)



5. ca channel blockers

Front 22

what happens to gfr when you start a pt on an ace/arb

Back 22

gfr goes down bc less perfusion pressure.

if it goes down a lot, the pt may have had renal artery stenosis, illness causing volume depletion, ischemic nephropathy without RAS (a small vessel disease)...

Front 23

benefits of RAAS blockade -

Back 23

less systemic BP, less glomerular capp pressure bc efferent arteriole dilation, less proteinuria

less macrophage infiltration, less inflammation, less oxidative stress.

Front 24

good to rx ace and arb together?

Back 24

controversial...

but you wanna give it at night bc ninght time HTN is higher assoc with stroke.

Front 25

no BP med works if...

Back 25

you have high salt intake.

Front 26

nutritional restrictions

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sodium, protein, alcohol, potassium (if hyperkalemic)

Front 27

after starting lisinopril...

Back 27

check K levels after a week!!!