eMedicine Specialties > Nephrology > The Kidney in Systemic Diseases

Diabetic Nephropathy: Differential Diagnoses & Workup

Author: Sandeep S Soman, MBBS, MD, DNB, Senior Staff Physician, Department of Internal Medicine, Division of Nephrology and Hypertension, Henry Ford Hospital
Coauthor(s): Anjana S Soman, MD, Staff Physician, Department of Pathology, Quest Diagnostics
Contributor Information and Disclosures

Updated: Jul 2, 2009

Differential Diagnoses

Multiple Myeloma
Renal Vein Thrombosis
Nephritis, Interstitial
Renovascular Hypertension
Nephrosclerosis
Nephrotic Syndrome
Renal Artery Stenosis

Other Problems to Be Considered

Diabetic nephropathy must be differentiated from cholesterol embolization, amyloidosis, and other glomerulopathies affecting patients with diabetes.

Workup

Laboratory Studies

  • Urinalysis
    • Regular annual urinalysis is recommended for screening for microalbuminuria (see image below and Image 4.). Typically, the urinalysis results from a patient with established diabetic nephropathy show proteinuria varying from 150 mg/dL to greater than 300 mg/dL, glucosuria, and occasional hyaline casts.
    • Microalbuminuria is defined as albumin excretion of more than 20 mcg/min. This phase indicates incipient diabetic nephropathy and calls for aggressive management, at which stage the disease may be potentially reversible (ie, microalbuminuria can regress).
    • A 24-hour urinalysis for urea, creatinine, and protein is extremely useful in quantifying protein losses and estimating the GFR.
    • Perform microscopic urinalysis to help rule out a potentially nephritic picture, which may lead to a workup to rule out other primary glomerulopathies, especially in the setting of rapidly deteriorating renal function (eg, rapidly progressive glomerulonephritis).
  • Blood tests - Blood tests, including calculation of GFR (by various formulas, such as the MDRD formula), are helpful in monitoring for the progression of kidney disease and in assessing its stage.


Screening for and prevention of the progression o...

Screening for and prevention of the progression of microalbuminuria in diabetes mellitus. (ACE-I stands for angiotensin-converting enzyme inhibitor)

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Screening for and prevention of the progression o...

Screening for and prevention of the progression of microalbuminuria in diabetes mellitus. (ACE-I stands for angiotensin-converting enzyme inhibitor)

Imaging Studies

  • Renal ultrasound
    • Observe for kidney size, which is usually normal to increased in the initial stages and, later, decreased or shrunken with chronic renal disease.
    • Rule out obstruction.
    • Perform echogenicity studies for chronic renal disease.

Procedures

  • Serum and urinary electrophoresis is performed mainly to help exclude multiple myeloma (in the appropriate setting) and to classify the proteinuria (which is predominantly glomerular in diabetic nephropathy).
  • Renal biopsy is not routinely indicated in all cases of diabetic nephropathy, especially in persons with a typical history and a progression typical of the disease. It is indicated if the diagnosis is in doubt, if other kidney disease is suggested, or if atypical features are present. Pathologic features are described in Pathophysiology.

Histologic Findings

See Pathophysiology.

Staging

See image below and Image 5.

Stages in the development of diabetic nephropathy.

Stages in the development of diabetic nephropathy.

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Stages in the development of diabetic nephropathy.

Stages in the development of diabetic nephropathy.

More on Diabetic Nephropathy

Overview: Diabetic Nephropathy
Differential Diagnoses & Workup: Diabetic Nephropathy
Treatment & Medication: Diabetic Nephropathy
Follow-up: Diabetic Nephropathy
Multimedia: Diabetic Nephropathy
References
Further Reading
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References

  1. Chiarelli F, Gaspari S, Marcovecchio ML. Role of growth factors in diabetic kidney disease. Horm Metab Res. May 18 2009;[Medline].

  2. Kostadaras A. Risk Factors for Diabetic Nephropathy. Astoria Hypertension Clinic. Available at http://www.kidneydoctor.com/dm.htm. Accessed 7/2/09.

  3. Shlipak M. Diabetic nephropathy. Clin Evid (Online). Jan 14 2009;2009:[Medline].

  4. Burney BO, Kalaitzidis RG, Bakris GL. Novel therapies of diabetic nephropathy. Curr Opin Nephrol Hypertens. Mar 2009;18(2):107-11. [Medline].

  5. Diabetes Guidelines. Royal Free Hampstead NHS Trust. Available at http://royalfree.org.uk/default.aspx?top_nav_id=1&sel_left_nav=25&tab_id=403. Accessed 7/2/09.

  6. Laight DW. Therapeutic inhibition of the renin angiotensin aldosterone system. Expert Opin Ther Pat. May 21 2009;[Medline].

  7. [Best Evidence] Wenzel RR, Littke T, Kuranoff S, et al. Avosentan reduces albumin excretion in diabetics with macroalbuminuria. J Am Soc Nephrol. Mar 2009;20(3):655-64. [Medline].

  8. Cooper ME. Pathogenesis, prevention, and treatment of diabetic nephropathy. Lancet. Jul 18 1998;352(9123):213-9. [Medline].

  9. Diabetes Control and Complications Research Group. Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial. Kidney Int. Jun 1995;47(6):1703-20. [Medline].

  10. Jacobsen P, Rossing K, Parving HH. Single versus dual blockade of the renin-angiotensin system (angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers) in diabetic nephropathy. Curr Opin Nephrol Hypertens. May 2004;13(3):319-24. [Medline].

  11. Matsuoka S, Awazu M. Masked hypertension in children and young adults. Pediatr Nephrol. Apr 8 2004;[Medline].

  12. Mogensen CE. The effect of blood pressure intervention on renal function in insulin-dependent diabetes. Diabete Metab. 1989;15(5 Pt 2):343-51. [Medline].

  13. Tanaka Y, Atsumi Y, Matsuoka K, et al. Role of glycemic control and blood pressure in the development and progression of nephropathy in elderly Japanese NIDDM patients. Diabetes Care. Jan 1998;21(1):116-20. [Medline].

  14. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. Sep 12 1998;352(9131):837-53. [Medline].

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Keywords

diabetic nephropathy, diabetes, nephropathy, kidney disease, renal disease, renal failure, kidney failure, diabetes mellitus, diabetes type 2, diabetes type 1, diabetic, diabetes 2, diabetes 1, proteinuria, retinopathy, diabetic retinopathy, diabetic neuropathy, albuminuria, microalbuminuria, type 2 diabetes, type 1 diabetes, hyperglycemia, glomerulosclerosis, type 2 diabetes mellitus, type 1 diabetes mellitus, persistent albuminuria, chronic renal failure, CRF

end-stage renal disease, ESRD, insulin-dependent diabetes, non-insulin-dependent diabetes, insulin-dependent diabetes mellitus, non-insulin-dependent diabetes mellitus, NIDDM, IDDM, diabetic glomerulopathy, Kimmelstiel-Wilson lesions, Kimmelstiel-Wilson nodules, chronic renal insufficiency, cellular hypertrophy, enhanced collagen synthesis, systemic hypertension

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Contributor Information and Disclosures

Author

Sandeep S Soman, MBBS, MD, DNB, Senior Staff Physician, Department of Internal Medicine, Division of Nephrology and Hypertension, Henry Ford Hospital
Sandeep S Soman, MBBS, MD, DNB is a member of the following medical societies: American College of Physicians, American Medical Association, and American Society of Nephrology
Disclosure: Nothing to disclose.

Coauthor(s)

Anjana S Soman, MD, Staff Physician, Department of Pathology, Quest Diagnostics
Anjana S Soman, MD is a member of the following medical societies: American Society for Clinical Pathology and College of American Pathologists
Disclosure: Nothing to disclose.

Medical Editor

Frank C Brosius III, MD, Nephrology Program Director, Professor of Internal Medicine and Physiology, Department of Internal Medicine, Division of Nephrology, University of Michigan School of Medicine
Frank C Brosius III, MD is a member of the following medical societies: Alpha Omega Alpha, American Diabetes Association, American Society of Nephrology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

George R Aronoff, MD, Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine
George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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