A 55 Year Old Diabetic Patient Presents With End Stage Renal Failure

A 55 year old man who is a known case of diabetes for almost 15 years presents with symptoms of end stage renal failure. His diabetes was mostly uncontrolled and his recent HbA1c level was 10. The patient has also been non compliant with his medicines. On examination the patient had bilateral lower extremity edema, and on laboratory workup he has a massive proteinuria. A biopsy of his kidney was done and following was seen on histopathology:

Glomeruli with Kimmelstiel-Wilson nodules. The smallest nodules can be more cellular and the greatest nodules tend to be acellular in the centre and surrounded by more cellular zones. Capillaries are seen around these nodules, sometimes adopting an aspect in garland (like in the three nodules indicated with arrows); in some cases we see microaneurisms around nodules. Notice the variability of size of the nodules (H&E, X.400).

The patient was diagnosed as a case of End stage Diabetic nephropathy.


Case Discussion:
Diabetic Nephropathy:

• Patients may be asymptomatic initially , but can later present with bilateral lower extremity edema (from nephrotic syndrome)
• patients with microalbuniminuria or proteinuria should be started on an ACE inhibitor to keep their BP < 120/80 mmHg
• End stage nephropathy requires chronic hemodialysis or transplantation.
• Kimmelstiel-Wilson lesions (nodular glomerulosclerosis) may be seen on kidney biopsy.

Kidneys are a major organs of the human body that remove waste products from the blood. Diabetic kidney disease is a complication that may occur in some patients with diabetes mellitus.

Pathophysiology:
The basic functional unit of the kidney is a nephron. A nephron consists of tiny blood capillaries that act as filters when blood flows through them. The waste products are excreted into the urine while the useful substance are returned back to the blood. In diabetes when there is high blood sugar levels it causes kidneys to filter too much blood and this work load slowly damages the filter system. Due to this damage the useful substances like proteins begin to leak and excreted into the urine. Gradually the the normal tissues are damaged and replaced by scar tissue leading to worsening of the normal kidney function finally leading to end stage renal disease when the kidneys cannot function to clean the blood of the waste products.

Microscopic Changes:When a kidney damaged by complications secondary to diabetes is examined under microscope it shows following gradual changes:

• Basement membrane thickening.- Earliest detectable change
• Expansion of mesangium and nodular sclerosis..
• Glomerular destruction and progressive nodular glomerulosclerosis.
• Deposits of glycogen in tubular epithelial cells.

Clinical Signs and Symptoms:
Early in the course of the disease there are almost no symptoms. The signs and symptoms usually begin to appear when most of the kidney function is already damaged. The symptoms of kidney disease are initially non-specific. When the disease becomes more severe patient may show symptoms like:

• Poor appetite
• Generalized body weakness
• Weight loss
• Fluid retention that causes swollen feet and ankles
• Puffiness of the face and around the eyes
• Pallor secondary to anemia
• Nausea and vomiting
• Increased frequency of urination
• Foamy or frothy appearance of urine.

Diagnosis: Diabetic nephropathy can be detected early by finding protein in the urine. Urine tests for protein are recommended for patients with diabetes every year.

• Normoalbuminuria: urinary albumin excretion <30 mg/24h, it is the physiological state;
• Microalbuminuria: urinary albumin excretion in the range of 30–299 mg/24h;
• Clinical (overt) albuminuria: urinary albumin excretion ≥300 mg/24h.

Treatment: In order to prevent and treat diabetic nephropathy following measures are suggested;

1. Keep blood sugar under strict control.

2. Keep blood pressure under control with values under 130/80 mmHg

3. Healthy life style changes by limiting the amount of salt intake, quitting to smoke, Losing weight if the patient is over weight, avoiding alcohol and getting regular exercise.

4. ACE inhibitors are the drugs of choice for patients with high blood pressure and diabetes to prevent renal complications.

5. Prompt treatment of urinary tract infections with appropriate antibiotics.

6. If the kidneys fail and reach end stage renal disease dialysis or transplant may be required.