eMedicine Specialties > Nephrology > The Kidney in Systemic Diseases

Diabetic Nephropathy: Follow-up

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: Nov 19, 2009

Follow-up

Further Inpatient Care

• Inpatient care is usually restricted to managing complications of diabetic nephropathy, such as volume overload, renal vein thrombosis, uremia complications (eg, pericarditis), and problems related to access.

Further Outpatient Care

• Regular outpatient follow-up is key in managing diabetic mellitum nephropathy successfully, with screening regularly for microalbuminuria, ensuring optimal glucose control, optimizing blood pressure, and screening for other associated complications of diabetes (eg, retinopathy, diabetic foot, cardiovascular disease).
• Pre-ESRD clinic referral is appropriate if the patient has overt diabetic nephropathy.

Deterrence/Prevention

• Optimal blood glucose control (Hba1c <7%)
• Control of hypertension (BP <120/70)
• Avoidance of potentially nephrotoxic substances such as nonsteroidal anti-inflammatory medications and aminoglycosides
• Early detection and optimal management of diabetes, especially in the setting of family history of diabetes

Complications

• Diabetic retinopathy is present in virtually all persons with IDDM who have nephropathy, whereas only 50-60% of patients with proteinuric NIDDM have retinopathy. An absence of retinopathy requires further investigation for nondiabetic glomerulopathies. Blindness due to severe proliferative retinopathy or maculopathy is approximately 5 times more common in persons with IDDM or NIDDM and nephropathy than in persons who are normoalbuminuric.
• Macroangiopathy (eg, stroke, carotid artery stenosis, coronary heart disease, peripheral vascular disease) is 2-5 times more common in patients who are nephropathic.
• Peripheral neuropathy is present in almost all patients with advanced nephropathy. Foot ulcers with associated sepsis, which leads to amputation, occur frequently (>25%), probably because of a combination of neural and arterial disease.
• Autonomic neuropathy may be asymptomatic and simply manifest as abnormal cardiovascular reflexes, or it may result in debilitating symptoms.
• Nearly all patients have grossly abnormal results from autonomic function tests, with more than half the patients with advanced nephropathy having symptoms of autonomic neuropathy (ie, gustatory sweating, impotence, postural hypotension, and diarrhea in one study).
• Diabetic cystopathy is also a frequent (>30%) problem in these patients.

Prognosis

• The overall prevalence of microalbuminuria and macroalbuminuria in both types of diabetes is approximately 30-35%. Diabetic nephropathy rarely develops before patients have had IDDM for at least 10 years, whereas approximately 3% of patients with newly diagnosed NIDDM have overt nephropathy.
• The peak incidence rate (3%/y) is usually found in persons who have had diabetes for 10-20 years, after which the rate progressively declines.
• Microalbuminuria independently predicts cardiovascular morbidity, and microalbuminuria and macroalbuminuria increase mortality from any cause in diabetes mellitus. Microalbuminuria also predicts coronary and peripheral vascular disease and death from cardiovascular disease in the general nondiabetic population.
• Patients in whom proteinuria did not develop have a low and stable relative mortality rate, whereas patients with proteinuria have a 40-fold higher relative mortality rate. Patients with IDDM and proteinuria have the characteristic bell-shaped relationship between diabetes duration/age and relative mortality, with maximal relative mortality in the age interval of 34-38 years (as reported in 110 females and 80 males).
• ESRD is the major cause of death, accounting for 59-66% of deaths in patients with IDDM and nephropathy. The cumulative incidence rate of ESRD in patients with proteinuria and IDDM is 50% 10 years after the onset of proteinuria, compared with 3-11% 10 years after the onset of proteinuria in European patients with NIDDM.
• Cardiovascular disease is also a major cause of death (15-25%) in persons with nephropathy and IDDM, despite their relatively young age at death.

Patient Education

• Patient education is key in trying to prevent diabetic nephropathy. Appropriate education, follow-up, and regular doctor visits are important in prevention and early recognition and management of diabetic nephropathy.
• For excellent patient education resources, visit eMedicine's Diabetes Center. Also, see eMedicine's patient education article Diabetes.
• For further information, see Mayo Clinic - Kidney Transplant Information.

Miscellaneous

Medicolegal Pitfalls

• Excluding the presence of other glomerular and nonglomerular diseases in a patient who is diabetic is important, especially if the diabetes is not of long-standing duration or no other typical features, such as proteinuria, or other associated manifestations of diabetes, such as retinopathy, are present.

Special Concerns

• Pregnancy in a patient with diabetic nephropathy does not seem to accelerate functional loss. More overt bacteruria, increased range of proteinuria, and hypertension may occur after mid gestation.

We wish to thank TKS Rao, MD, Associate Director, Renal Diseases Division, Professor, Department of Medicine, State University of New York Downstate Medical Center.

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