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  • 1. Diabetic Nephropathynew horizonDr. Muhamed Al Rohani,MD

2. DefinitionClassical definition: progressive rise in urine albuminexcretion coupled with increasing BP and leadingto declining GFR and CKDAbnormal urine albumin excretion >30 mg/24 hoursand/ordiabetic glomerular lesionsand/orloss of glomerular filtration rateADA recommendations, Diabetes Care, January 2012 3. Prevalence Incidence 4. EpidemiologyIncrease prevalence of DMIndia china USA4% 1995 5.4% 2025Worldwide:2.8 % 171 million 2000 4.4% 366 million 2030Now: USA 7% (20.8 million) offpopulation has DMDN prevalenceIn India: 5.5% and 8.9%Asian Indians in UK 22.3%Increased mortality rateWith protinuriaWithout proteinuriaIncreased CV events 5. Harris MI. Clin Invest Med. 1995;18:231-239.Nelson RG, et al. Adv Nephrol Necker Hosp. 1995;24:145-156.World Health Organization. Diabetes Mellitus Fact Sheet 138. 2002.ADA. National diabetes fact sheet. Available at:http://www.diabetes.org/diabetes-statistics/national-diabetes-fact-sheet.jsp.Microvascular Complications Macrovascular ComplicationsComplications of Type 2 DiabetesAffect Every Part of the BodyPeripheralVascular DiseaseHeartDiseaseDiabetic RetinopathyLeading cause ofblindness inworking-age adultsDiabetic NephropathyLeading cause ofend-stage renal diseaseDiabetic NeuropathyLeading cause ofnontraumatic lowerextremity amputationsStroke2- to 4-fold increasein cardiovascularmortality and stroke 6. Specific Infections Community acquiredpneumonia Acute bacterial cystitis Acute pyelonephritis Emphysematouspyelonephritis Perinephric abscess Fungal cystitis Necrotizing fasciitis Invasive otitis externa Rhinocerebralmucormycosis Emphysematouscholecystitis 7. Natural history of DN 8. Type IDuration:Microalbuminuria after 20 yrs in 20 30 % of DM patientsESRD after 10 yrs,Type 2Duration:CKD or ESRD in 1% of pts in the time ofdiagnosisESRD in 20 -30 % at 20 yrs.Poor glycemic controlStrict control reduce and slow the risk of microvascular and evenmacrovascular complications.Hypertension:Cause of and results of diabetic renal diseaseIn DM1 5% in 10 yrs33% in 20 yrs70% in 40 yrsRise with 3 yrs of microalbuminuria with Incidence of 15 25%75 85% in all diabetic nephropathy 9. Effect of Increased Glomerular Permeability to Proteins on Progressive Renal Injury.Remuzzi G, Bertani T. N Engl J Med 1998;339:1448-1456.Gilbert RE, Marsden PA. N Engl J Med 2008;358:1628-1630. 10. Flow chart for classifying DN.Tervaert T W C et al. JASN2010 by American Society of Nephrology 11. Representative examples of the morphologiclesions in DN. (A) Glomerulus showing only mildischemic changes, with splitting of Bowmanscapsule.2010 by American Society of Nephrology 12. Pathological classification of DNClass Description Inclusion CriteriaIMild or nonspecific LM changes andEM-proven GBM thickeningBiopsy does not meet any of the criteria mentioned belowfor class II, III, or IVGBM > 395 nm in female and >430 nm in male individuals9 years of age and olderaIIaMild mesangial expansionBiopsy does not meet criteria for class III or IVMild mesangial expansion in >25% of the observedmesangiumIIbSevere mesangial expansionBiopsy does not meet criteria for class III or IVSevere mesangial expansion in >25% of the observedmesangiumIII Nodular sclerosis (KimmelstielWilson lesion)Biopsy does not meet criteria for class IVAt least one convincing KimmelstielWilson lesionIV Advanced diabeticglomerulosclerosisGlobal glomerular sclerosis in >50% of glomeruliLesions from classes I through III 13. Treatment of Diabetic NephropathyHypertension Control - Goal: lower blood pressure to