Progressive kidney disease caused by damage to the capillaries in the glomeruli

Pathophysiology

• It is characterised by proteinuria and diffuse scarring of the glomeruli
• Also known as Kimmelsteil-Wilson Syndrome or Nodular Glomerulosclerosis

Investigations

1. If ACR <30 or PCR <50 = microalbuminuria
   1. Repeat twice as false positive readings are common
   2. Established microalbuminuria if 2/3 positive
   3. Microalbuminuria will not show up as protein++ on urine dipstick
2. If ACR >30 or PCR >50 = proteinuria (overt nephropathy)
   1. Repeat on EMU
   2. Proteinuria will show up on a urine dipstick

Management

• Presence of microalbuminuria requires treatment with ACEi/ARB
  • Dilate renal arterioles so decrease filtration pressure → decrease proteinuria (also decreases GFR - allow up to 20% deterioration in GFR)
• Diabetic patients with microalbuminuria should be started on an SGLT2i (irrespective of HBA1c)
• Manage other vascular complications e.g. discourage smoking, assess fasting lipid profile, screen for cardiovascular disease and hypertension
  • Target BP is <140/80 mmHg for all patients with diabetes
• Aggressive treatment of blood pressure, glycaemia and use of ACEi/AGLT2i can prevent decline in renal function

Prevention

• Good glycaemic control (53 mmol/mol) in patients with T2DM should be maintained to reduce the risk of developing diabetic neuropathy (depending on age and other risk factors

Complications

• Development of hypertension
• Relentless decline in renal function
  • Reduction in GFR of 1ml/min/month if untreated
• Accelerated vascular disease
• Microalbuminuria is a sign of damage to the glomeruli causing protein leak
  • Marker of 'high risk' of other vascular problems