We will move on to diabetic nephropathy.
I showed you images, we had a discussion of
diabetic nephropathy in nephrology.
Make sure that we are complete.
20-30 percent of all patients with DM develop
nephropathy, that’s a huge percentage.
The most common cause of renal failure is
The changes that are taking place, if you
remember with nephropathy include both the
blood vessels and then also within the mesangium,
What happens first?
It is the blood vessels first and if you have
arterioles that have been affected then you
call this Hyaline Arteriosclerosis, hyalinization.
And for the most part, if there is diabetic
damage to the kidney, one of the first signs
that you will be looking for upon urinalysis
called microalbuminuria, microalbuminuria.
What are you going to put this patient on
immediately to preserve the functioning of
ACE inhibitor is renal protective and the
reason for that is because it removes the
affective angiotensin 2 which prefers to work
upon the efferent arterial vasoconstriction.
Unbelievably, in diabetic nephropathy tends
to develop hyaline arteriosclerosis on the
And so, therefore, if you constrict the efferent
pathologically, you are then causing damage
to the glomerulus.
So, why don’t we then ease up some of that
stress and that constriction of the efferent
arterial by giving an ACE inhibitor?
Screen with microalbuminuria, begin shortly
after type 2 diabetes and 5 years after type
Annually, they are after… it is important
that you are always paying attention to retinopathy,
nephropathy, retinopathy, nephropathy and
obviously neuropathy, the 3Ns.
Elevated use of micro albumin maybe secondary
to fever, exercise, infection.
So, other, other causes or differentials that
may result in microalbuminuria, keep that
However, diabetes mellitus extremely important
ACE inhibitor removes the angiotensin 2 and
so, therefore, you would use this as soon
as you would find microalbuminuria.
With microalbuminuria, 30 to 299 mg per 24
hours; if it is clinical then it is greater
Blood pressure goal here is important.
You want to keep your blood pressure less
than 130/80 for all patients of DM, remember
the normal is 120/80.
By definition, hypertension clinically is
130/80, you want to be quite aggressive with
controlling the blood pressure in your diabetic
and also hyperlipidemia as well.
Glomerular lesions, what we are seeing here
in this picture is in fact your Kimmelstiel-Wilson
What you are seeing at the very… in the
mesangium, that dark area and in the next
picture, I will show it you as well which
is the one that we have seen prior, these
are known as your Kimmelstiel-Wilson nodules.
There is also going to be tubular lesions,
but before I show you this in the bottom picture,
I want you to identify the mesangium of the
You see the area that’s homogenously pink,
that’s in the mesangium and that is in fact
your Kimmelstiel-Wilson nodules.
However, in addition to that, you also find
in the peripheries, go outside the glomerulus
and what you are seeing there with a little
bit of blood and such, those tubes that you
are seeing are not blood vessels, the tubes
that you are seeing there in fact are your
tubules and this is then referred to in diabetes
as being your Armanni-Ebstein lesion.
Hyperglycemia resulting in tubular deposition
of glycogen, tubular lesions, blood vessel
lesions, mesangial lesions all leading into
eventual renal failure and with diabetic nephropathy,
you would expect there to be a nephrotic type