Nephropathy diabetic

The nephropathy diabetic is one of the most frequent complications and most frightening of the Diabète sweetened, which makes fear the evolution towards a chronic Impaired renal function. It relates to at the same time the Diabète of the type 1 and of the type 2, but the evolution of the disease is appreciably different in these two cases: diabetes of the type 1 fact of fearing the impaired renal function initially, whereas nephropathy diabetic of type 2 has especially a bad cardiovascular forecast.

Tracking

It rests on the annual proportioning of the microalbuminurie in the Urine S 24 hours: one measures the mass of Albumine excreted by the Rein S during one day, which is normally null (albumin is principal the Protéine plasma tick, it does not pass normally in the urines) but whose presence testifies to anomalies of glomerular filtration. The microalbuminurie becomes pathological from 30 mg/jour, beyond 300 mg/j one speaks about protéinurie.

In the diabetic of the type 1, the appearance of a microalbuminurie makes fear the evolution towards the protéinurie (concerning classically 85% of the patients) then the impaired renal function (reached into 15 to 20 years on average): it is of which the renal forecast which is in first line and will be the target of the treatment.

In the diabetic of the type 2, the evolution towards the protéinurie is less frequent (25% of the cases), the microalbuminurie testifying then to vascular lesion severe and diffuse: the cardiac forecast is threatened (the renal attack is a cardiovascular risk factor independent).

Diagnosis

The diagnosis is strongly suspecté in front of the appearance of a Microalbuminurie or a Protéinurie at a subject diabetic. However, the diagnosis of certainty can be brought only by a renal Biopsie. One can however not there not have recourse most of the time, when the Maladie is typical: the diabetes has evolved/moved for more than 5 years, the protéinurie is progressive and impure (with arterial Hypertension, but without Hématurie), the size of the kidneys is increased, it exists a Rétinopathie diabetic (these two complications chronic result from same the pathological mechanisms, which reveals them at the same time during the disease: thus, the discovery of one or other of these complications must inevitably make seek the other, and finds it in the near total of the cases).

Classification of Mögensen

It describes the successive evolution of the disease, from a histological point of view and biological, in the case of the diabetes of the type 1 (well better known than type 2).

Stage 1: glomerular hyperfiltration

The glomerular flow of filtration is increased of more than 20%, associated with an increase in the size of the kidneys. There is at this stage neither microalbuminurie, nor Symptôme.

Stage 2: tiny histlogic lesions

The glomerular basal membrane is thickened, as well as the Artériole S related and efferent with the cluster. There exists an intermittent microalbuminurie.

Stage 3: nephropathy incipiens

The microalbuminurie becomes permanent: it is the first detectable stage of the disease. It evolves to stage 4 into 5 to 10 years.

Stage 4: proven nephropathy

There exists a permanent protéinurie, the main risk is the evolution towards a nephrotic Syndrome and a final impaired renal function, reached into 5 to 10 years, generally in the diabetic of the type 1.

Stage 5: chronic impaired renal function

This stage, like any IRC, requires to be dialyzed, to see a Clerc's Office of kidney (or kidney + pancreas grafts)

Treatment

In the Diabetes of the type 1

The main aim is, like known as higher, to save the kidney.

the most important measurement is the strict balance of the diabetes reinforced by a monitoring and a therapeutic relation without fault. Control glycemic by the patient must be quite comparable, and one will control periodically the rate of glyquée Hémoglobine (which must be lower than 6,5%).
the nephroprotector treatment rests on the prescrition of a Inhibiteur of the enzyme of conversion (or IEC ) to full amount in the event of hypertension, low dose if not. The objective tensionnel is of 125/75 mmHg (Blood-pressure systolic/diastolic).
One founds a mode restricted in Protéine S (approximately 30 mg/kg/jour)
Enfin, it will be necessary to take care to avoid all the factors of aggravation of the impaired renal function when it appears.

In the Diabetes of the type 2

The treatment is the same one, but following measurements are added (while keeping in mind which the main risk here is the death by cardiovascular complications):

strict balance of the blood-pressure,
tracking and treatment of all the other cardiovascular risk factors (Nicotinism, Obesity, Hyperlipidémie, sedentariness),
stop of the Antidiabétique S oral examinations in the event of proven impaired renal function,

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