Renal: Diabetic Nephropathy

Front 1

Hyperfiltration (Increased GFR) is common in EARLY Type __1__ diabetics. It is transient, but associated with __2___. It also causes ___3____ renal and glomerular size. ___4____ may play a role in this.

Back 1

1) Type I
2) Episodes of poor blood sugar control
3) an increase
4) IGF-1

Front 2

1) Define diabetic nephropathy

Back 2

1) persistent albuminuria >300mg/day. Ususally associated with decreased GFR and increased BP.

Front 3

Most common cause of need for dialysis

Back 3

Diabetic nephropathy

Front 4

1) Risk factors in T1DM for developing Diabetic nephroapthy?
2) Risk factors in T2DM for developing Diabetic nephroapthy?

Back 4

1) Duration of disease, poor glucose control
2) HTN, smoking, ethnicity (blacks, Naive Americans, mexicans, asians)

Front 5

Hallmark of diabetic nephropathy

Back 5

proteinuria

Front 6

Phases of DN
1) Normal Urine protein
2) Miroalbuminuria
3) Diabetic Nephropathy (Macroalbuminuria)

Back 6

1) <30 mg/day
2) 20-300 mg/day
3) >300 mg/day (positive dipstick)

Front 7

1) Mechanism of Microalbuminuria
2) Mechanism of Overy DIabetic nephropathy (macroprtoeinuria)

Back 7

1) Increased glomerular pressure (GFR may be elevated)
2) Larger filtration pores

Front 8

What is the difference in urine protein composition in micro and hen macroproteinura

Back 8

In micro, it is albumin selective. In macro (overt DN), there is more IgG and it is not selective for albumin.

Front 9

What health parameter most determines the rate of GFR decrease per year in DN?

Back 9

1) Hypertension

max rate of loss is 20 mL/min/year
Well controlled HTN= 1-2 mL/min/year

Front 10

In general 50% of patiets with DN develop CKD in __1__ years.

Back 10

10

Front 11

Does the diagnosis of DN require renal biospy?

Back 11

No

Front 12

1) In DN in DM1, what other symptom is most often seen with kidney dysfunction
2) What aout in DM2?

Back 12

1) Retinopathy
2) HTN

Front 13

When would one use a biospy in the case of sspected diabetic nephropathy?

Back 13

Atypia-
Short Hx of DM
Rapid decline in renal function
Suspicion of other treatable disease

Front 14

1) What is the first symptom of DN
2) What is the minimum time after DM onset that it should occur?

Back 14

1) microalbuminemia
2) 5 years.

Front 15

Name the three pathways that Diabetes can cause renal dysfunction

Back 15

Increased non-enzymatic glycosylation**
Increased aldose reductase pathway
PKC activation

Front 16

How does non-enzymatic glycosylation cause renal dysfucntion

Back 16

Causes Advanced gylcation products (AGEs) y interaction with lysine groups. This renders BM collagen unable to be degraded. Also has receptors on endothelial cells and macrophages that may cause altered matrix production.

Front 17

How does activation of the aldose reductase pathway cause renal dysfucntion?

Back 17

Converts glucose to sorbitol which may cause increased intracellular osmolality and depletion of intracellular myo-inositol and inhibition of Na/K ATPase.

Front 18

How does activatio of PKC cause renal dysfucntion?

Back 18

induced by hyperglycemia, increases vascular reactivity

Front 19

How do ACEI and ARBs function to slow diabetic nephropathy

Back 19

dilate efferent arteriole, lowering intraglomerular pressure.

Front 20

1) Does intnsive glucose control matter in microalbuminuria?
2) In Diabetic nephropathy?

Back 20

1) yes it can slow but not halt progression to DN
2) No, does not change decline of renal function.

Front 21

1) With microalbuminuria, who should get ACE or ARB therapy?
2) Should ACE/ARB
be therapy be given to all people with DN?
3) ACEI or ARB therapy for DN is titrated until what target BP?
4) and what amount of proteinuria?

Back 21

1) EVERYONE, hypertensive or normotensive. Decreases progression to DN.
2) yes, reduces progression of renal disease
3) 125/80
4) <1g/day or at least 60% reduction

Front 22

1) When is urinary albumin screening measurement receommended for T1DM?
2) T2DM
3) Why do they differ?
4) When is it recommended to start ACE-I or A2RB?

Back 22

1) Not for first 5 years.
2) at time of Dx
3) Hard to pinpoint onset of T2DM
4) At time Microalbuminuria is detected

Front 23

Two Other renal/urinary sequelae of Diabetes

Back 23

1) Neurogenic bladder (retention)
(Can lead to an obstructive nephropathy)
2) UTI's are more severe with more chance of abcss formation, sepsis, and pyelonephritis, and papillary necrosis.

Front 24

1) most common cause of renal disease requiring dialysis or transplant
2) Second most common?

Back 24

1) Diabetic Nephropathy
2) HTN

Front 25

What type of kidney damage is causes by HTN?

Back 25

1) Hypertensive nephrosclerosis

Front 26

1) Describe the typical demographics and Hx of a person who has hypertensive nephrosclerosis.
2) What is the commonly associated cardiac finding?
3) Proteinuria?
4) Hematuria?

Back 26

1) Male, over 50, African American
HAS NOT seen a doctor for a long time
2) LVH
3) Elevated, but non-nephrotic range. (nephrotic presentation is uncommon)
4) Not present. Hematuria should cause evaluation for another cause.

Front 27

Two things that we always do to work up a person with hypertensive nephrosclerosis

Back 27

Protein quantification
Renal ultrasound

Biopsy is rare

Front 28

1) Aside from lifestyle modification and home BP monitoring, what should ALWAYS be included in the Tx for Hypertensive kidney disease?
2) Target BP in this case?

Back 28

1) ACE-I or ARB
2) 135/85

Front 29

1-2) Two most common causes of Renal artery narrowing (secondary renal HTN)?

3) presentation of these people?

Back 29

1) Atherosclerosis
2) Fibromuscular dysplasia
3) Recent onset sever HTN

Front 30

1-3) Three clinical features shared by people with fibromuscular dysplasia and renal artery atherosclerosis?
4) The DIFFERENT Age ranges of these people

Back 30

1) Other vascular disease
2) Smoking
3) Refractory HTN
4) FMD- <30 YO
Atherosclerosis- >60 YO

Front 31

1) What is the central hormonal change in unilateral renal artery stenosis?
2) What does this cause?
3) does it cause Na+ rentention? Why?
4) Under what case could Na+ be retained?

Back 31

1) Increased Renin from ipsilateral kidney
2) Vasconstriction, fluid retention
3) No, due to pressure natriuresis in the contralateral kidney.
4) Bilateral stenosis

Front 32

1) What changes does a stenosed renal artery cause in the kidney
2) If this is suspected, what imaging do we do?
3) If this is positive, what further imaging do we do?
4) IF this shows true atheroma, what do we do to treat it?

Back 32

Ischemic nephropathy giving apoptosis and scarring
2) Renal magnetic resonance angiography (MRA)
3) Renal angiography
4) Percutaneous Renal artery balloon angioplasty