Diabetic nephropathy – the specific pathological changes of kidney vessels arising at diabetes of both types and leading to a glomeruloskleroz, decrease in filtrational function of kidneys and development of the chronic renal failure (CRF). The diabetic nephropathy is clinically shown by a mikroalbuminuriya and a proteinuria, arterial hypertension, a nephrotic syndrome, symptoms of uraemia and HPN. The diagnosis of a diabetic nephropathy is based on determination of level of albumine in urine, clearance of endogenous creatinine, the proteinaceous and lipidic range of blood germinated by ultrasonography, UZDG of kidney vessels. In treatment of a diabetic nephropathy the diet, correction of carbohydrate, proteinaceous, fatty exchange, reception of APF and MACAW inhibitors, dezintoksikatsionny therapy, if necessary – a hemodialysis, transplantation of kidneys are shown.
The diabetic nephropathy is a late complication of diabetes of 1 and 2 types and one of the main reasons for death of patients with this disease. The injuries of large and small blood vessels developing at diabetes (diabetic a macrovascular disease and a mikroangiopatiya) promote defeat of all bodies and systems, first of all, of kidneys, an eye, nervous system.
The diabetic nephropathy is observed at 10-20% of patients with diabetes; slightly more often the nephropathy complicates a current of insulin-dependent type of a disease. The diabetic nephropathy is revealed more often at male patients and at persons with diabetes of 1 type, developed at pubertatny age. The peak of development of a diabetic nephropathy (HPN stage) is observed lasting diabetes of 15-20 years.
Reasons of a diabetic nephropathy
The diabetic nephropathy is caused by pathological changes of kidney vessels and balls of the capillary loops () performing filtrational function. Despite various theories of pathogenesis of a diabetic nephropathy considered in endocrinology, a major factor and a starting link of its development is the hyperglycemia. The diabetic nephropathy arises owing to long insufficient compensation of violations of carbohydrate exchange.
According to the metabolic theory of a diabetic nephropathy, the constant hyperglycemia gradually leads to changes of biochemical processes: to a non-enzymatic glycosylation of proteinaceous molecules of kidney balls and decrease in their functional activity; to violation of a water and electrolytic homeostasis, exchange of fatty acids, reduction of oxygen transport; activization of a poliolovy way of utilization of glucose and toxic action on tissue of kidneys, to increase in permeability of kidney vessels.
The haemo dynamic theory in development of a diabetic nephropathy assigns the main role to arterial hypertension and violations of an intra kidney blood-groove: to an imbalance of a tone bringing and taking out and to increase in blood pressure in balls. Long hypertensia leads to structural changes of balls: at first to a hyper filtration with the accelerated formation of primary urine and an exit of proteins, then - to replacement of fabric of a kidney ball with a connecting (glomeruloskleroz) with full occlusion of balls, decrease in their filtrational ability and development of a chronic renal failure.
The genetic theory is based on presence at the patient with a diabetic nephropathy of genetically determined contributing factors which are shown at exchange and haemo dynamic violations. Participate in pathogenesis of a diabetic nephropathy and closely all three mechanisms of development interact among themselves.
Risk factors of a diabetic nephropathy are arterial hypertension, a long uncontrollable hyperglycemia, infections of uric ways, violations of fatty exchange and the excess weight, a male, smoking, use of nefrotoksichny medicines.
Symptoms of a diabetic nephropathy
The diabetic nephropathy is slowly progressing disease, her clinical picture depends on a stage of pathological changes. In development of a diabetic nephropathy distinguish stages of a mikroalbuminuriya, a proteinuria and a terminal stage of a chronic renal failure.
For a long time the diabetic nephropathy proceeds asymptomatically, without any external manifestations. At an initial stage of a diabetic nephropathy increase in the size of balls of kidneys (a hyper functional hypertrophy), strengthening of a kidney blood-groove and increase in the speed of a glomerular filtration (SGF) is noted. Several years later from a debut of diabetes initial structural changes of the glomerular device of kidneys are observed. The high volume of a glomerular filtration remains, the albumine ekskretion with urine does not exceed normal indicators (
The beginning diabetic nephropathy develops more than in 5 years from the beginning of pathology and is shown by a constant mikroalbuminuriya (> 30-300 mg/days or 20-200 mg/ml in a morning portion of urine). Periodic increase in arterial pressure can be noted, especially at physical activity. Deterioration in health of patients with a diabetic nephropathy is observed only at late stages of a disease.
Clinically expressed diabetic nephropathy develops in 15-20 years at diabetes of 1 type and is characterized by the resistant proteinuria (protein level in urine –> 300 mg/days) testifying to irreversibility of defeat. The kidney blood-groove and SKF decrease, arterial hypertension becomes constant and difficult korrigiruyemy. The nephrotic syndrome which is shown a gipoalbuminemiya, a hypercholesterolemia, peripheral and band hypostases develops. Levels of creatinine and urea of blood are normal or are slightly increased.
At a terminal stage of a diabetic nephropathy sharp decrease in filtrational and concentration functions of kidneys is noted: a massive proteinuria, low SKF, significant increase in level of urea and creatinine in blood, development of anemia, the expressed hypostases. At this stage the hyperglycemia, a glucosuria, an ekskretion with urine of endogenous insulin, and also the need for exogenous insulin can decrease considerably. The nephrotic syndrome progresses, HELL reaches high values, the dispepsichesky syndrome, uraemia and HPN with symptoms of self-poisoning of an organism with products of exchange and defeat of various bodies and systems develops.
Diagnostics of a diabetic nephropathy
Early diagnostics of a diabetic nephropathy represents the major task. For the purpose of establishment of the diagnosis of a diabetic nephropathy carry out biochemical and general blood test, the biochemical and general analysis of urine, Reberg's test, Zimnitsky's test, UZDG of vessels of kidneys.
The main markers of early stages of a diabetic nephropathy are the mikroalbuminuriya and speed of a glomerular filtration. At annual screening of patients with diabetes investigate a daily ekskretion of albumine with urine or a ratio albumine/creatinine in a morning portion.
Transition of a diabetic nephropathy to a stage of a proteinuria is determined by availability of protein in the general analysis of urine or an ekskretion of albumine with urine by higher than 300 mg/days. HELL, signs of a nephrotic syndrome is noted increase. The late stage of a diabetic nephropathy does not represent complexity for diagnostics: to a massive proteinuria and decrease in SKF (less than 30 - 15 ml/min.), increase of levels of creatinine and urea is added to blood (azotemiya), anemia, acidosis, a gipokaltsiyemiya, a giperfosfatemiya, a giperlipidemiya, face edemas and all body.
It is important to carry out differential diagnostics of a diabetic nephropathy with other diseases of kidneys: chronic pyelonephritis, tuberculosis, sharp and chronic glomerulonefrit. For this purpose the bacteriological research of urine on microflora, by ultrasonography of kidneys, excretory urography can be carried out. In certain cases (at early the developed and quickly accruing proteinuria, sudden development of a nephrotic syndrome, resistant gematuriya) for specification of the diagnosis the tonkoigolny aspiration biopsy of a kidney is carried out.
Treatment of a diabetic nephropathy
The main objective of treatment of a diabetic nephropathy - to warn and as much as possible to delay further progressing of a disease to HPN, to reduce risk of development of cardiovascular complications (IBS, a myocardial infarction, a stroke). The general in treatment of different stages of a diabetic nephropathy is strict control of sugar of blood, HELL, compensation of violations of mineral, carbohydrate, proteinaceous and lipidic exchanges.
Medicines of the first choice in treatment of a diabetic nephropathy are inhibitors of angiotenzinprevrashchayushchy enzyme (APF): enalaprit, ramiprit, trandolaprit also antagonists of receptors to angiotensin (MACAW): , , , the diseases normalizing system and intra glomerular hypertensia and slowing down progressing. Medicines are appointed even at normal indicators HELL in the doses which are not leading to development of hypotonia.
Since a mikroalbuminuriya stage, the reduced-protein, saltless diet is shown: restriction of consumption of animal protein, potassium, phosphorus and salt. Are necessary correction of a dislipidemiya at the expense of a diet with the low content of the fats and administration of drugs normalizing a lipidic range of blood for decrease in risk of development of cardiovascular diseases (L-arginina, folic acid, statin).
At a terminal stage of a diabetic nephropathy dezintoksikatsionny therapy, correction of treatment of diabetes, reception of sorbents, protivoazotemichesky means, normalization of level of hemoglobin, prevention of osteodystrophy is required. At sharp deterioration in function of kidneys the question of carrying out to the patient of a hemodialysis, continuous peritonealny dialysis or surgical treatment is raised by method of transplantation of a donor kidney.
Forecast and prevention of a diabetic nephropathy
Mikroalbuminuriya at in due time appointed adequate treatment is the only reversible stage of a diabetic nephropathy. At a stage of a proteinuria the prevention of progressing of a disease to HPN is possible, achievement of a terminal stage of a diabetic nephropathy leads to the state not compatible to life.
Now the diabetic nephropathy and HPN developing owing to it are the leading indications to replacement therapy - a hemodialysis or transplantation of a kidney. HPN owing to a diabetic nephropathy the reason of 15% of all lethal outcomes among patients with diabetes of 1 type serves younger than 50 years.
Prevention of a diabetic nephropathy consists in systematic observation of patients with diabetes at the endocrinologist-diabetologa, timely correction of therapy, constant self-checking of level of a glycemia, observance of recommendations of the attending physician.