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and type IV (hyporeninemic hypoaldosteronemic) renal tubular acidosis Patients are more susceptible to acute renal failure from contrast material and have a poor prognosis once dialysis is begun
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Barnett AH et al; Diabetics Exposed to Telmisartan and Enalapril Study Group Angiotensin-receptor blockade versus convertingenzyme inhibition in type 2 diabetes and nephropathy N Engl J Med 2004 Nov 4;351(19):1952 61 [PMID: 15516696] Finne P et al Incidence of end-stage renal disease in patients with type 1 diabetes JAMA 2005 Oct 12;294(14):1782 7 [PMID: 16219881] Remuzzi G et al Clinical practice Nephropathy in patients with type 2 diabetes N Engl J Med 2002 Apr 11;346(15): 1145 51 [PMID: 11948275] Ruggenenti P et al; Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) Investigators Preventing microalbuminuria in type 2 diabetes N Engl J Med 2004 Nov 4; 351(19):1941 51 [PMID: 15516697] Strippoli GF et al Effects of angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists on mortality and renal outcomes in diabetic nephropathy: systematic review BMJ 2004 Oct 9;329(7470):828 [PMID: 15459003]
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Diabetic nephropathy is the most common cause of ESRD in the United States (about 4000 cases a year) Type 1 diabetes mellitus carries a 30 40% chance of nephropathy after 20 years, whereas type 2 has a 15 20% chance after 20 years ESRD is much more likely to develop in persons with type 1 diabetes mellitus, probably because of fewer comorbidities and deaths before ESRD ensues With the current epidemic of type 2 diabetes mellitus, rates of diabetic nephropathy are projected to continue to increase over at least the next 2 decades Patients at higher risk include males, African Americans, and Native Americans The nephrotic syndrome develops in patients at risk for nephropathy Diabetic retinopathy is often present in these patients Initial screening of diabetics should always include urine examination for microalbuminuria Dipstick examination may not be sensitive enough; a 24-hour urine collection is the accepted standard measure (An albumin excretion of > 30 mg/d is abnormal) However, an early morning spot urine albumin or albumin-creatinine ratio is adequate (More than 30 mg of albumin per gram of creatinine is considered abnormal) In patients prone to nephropathy, microalbuminuria will develop within 10 15 years after onset of diabetes and progress over the next 3 7 years to overt proteinuria During the onset of subclinical proteinuria, aggressive treatment is necessary Strict glycemic control and treatment of hypertension have been proven to slow progression of disease In particular, ACE inhibitors and ARBs lower the rate of progression to clinical proteinuria and slow progression to ESRD They may reduce intraglomerular pressure as well as treat hypertension Even in the subset of patients with markedly diminished renal function, these agents seem to provide renal benefit if patients can tolerate the medication from the perspective of hyperkalemia and the acute decrease in GFR The most common lesion in diabetic nephropathy is diffuse glomerulosclerosis, but nodular glomerulosclerosis (Kimmelstiel-Wilson nodules) is pathognomonic The kidneys in these patients are usually enlarged as a result of cellular hypertrophy and proliferation At the onset of diabetic nephropathy, glomerular disease will cause an increase in GFR As the nephropathy progresses, with the development of macroalbuminuria, the GFR returns to normal and continues to decrease Patients with diabetes are prone to other renal disease These include papillary necrosis, chronic interstitial nephritis,
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HIV-associated nephropathy can present as the nephrotic syndrome in patients with HIV infection Most patients are young black men In these patients, the more common mode of acquisition of HIV is through injection drug use Patients can have a nephrotic picture with normal complement levels Light microscopy shows focal segmental glomerulosclerosis as described above Lesions can be of the collapsing variety and often exhibit severe tubulointerstitial damage Small, uncontrolled studies have shown that highly active antiretroviral therapy (HAART) for a prolonged course can slow progression of disease Despite this minimal evidence, HAART has been recommended for use in these patients given the therapy s other beneficial effects and reasonable toxicity profile Corticosteroid treatment has been used with variable success at a dosage of 1 mg/kg/d along with cyclosporine and ACE inhibitors
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Szczech LA et al The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection Kidney Int 2004 Sep;66(3):1145 52 [PMID: 15327410]
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