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Diabetic Nephropathy |
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The kidney is frequently affected in diabetes
mellitus
As patients with diabetes mellitus frequently suffer renal disease, monitoring
of renal function is
an important part of follow-up.
Diabetes is now one of the most common causes of
end-stage renal
failure.
The associated renal disease can be divided into three forms:
complications of
diabetic vascular disease, diabetic glomerular damage, and increased
susceptibility to infection
and papillary necrosis.
Diabetes causes increased severity of atherosclerosis in large, medium and small
arteries, predisposing
to renal ischaemia.
In addition, diabetes causes hyaline arteriolosclerosis in
afferent arterioles,resulting in ischaemic glomerular damage.
Diabetic glomerular damage involves diffuse thickening of the glomerular
capillary basement
membrane leading to an increase in permeability, proteinuria and,
occasionally, the nephrotic syndrome.
Exudative lesions due to a combination of
thick permeable
basement membrane and abnormal mesangium may be visible as masses of
red-staining coagulated
fibrin protein (fibrin caps) on the surface of the glomerulus.
Changes in mesangium lead to excess mesangial matrix formation.
This initially occurs in an even pattern throughout the glomerulus (diffuse
diabetic glomerulosclerosis),
but later takes the form of laminated spheres, which are known as
'Kimmelstiel-Wilson nodules' (nodular diabetic glomerulosclerosis)
Diabetic glomerulosclerosis causes progressive hyalinization of glomeruli, with
obliteration of
capillary loops and death of individual nephrons.
Over a period of years this leads to chronic renal failure.
The most important infiltrative disease of the glomerulus is amyloidosis
The kidney is a target organ in amyloidosis, a condition in which extracellular
fibrillar
protein is deposited in a variety of tissues.
For a more detailed discussion, see amyloidosis.
The amyloid is deposited as fibrils in the GBM and in the mesangium. As amyloid
is deposited
in the basement membrane, the membrane thickens and its permeability is
increased, so that the
first manifestation is proteinuria. With heavy deposition of amyloid, the
protein loss
increases until the patient develops features of the
nephrotic syndrome.
Amyloid is an important cause of the nephrotic syndrome in adults. Heavy amyloid
deposition
in the mesangium, in combination with increased mesangial matrix formation, can
eventually
lead to expansion of the mesangium, ultimately leading to compression of the
glomerular capillary
system, and transition into chronic renal failure.
Amyloid is also deposited in
the walls
of intrarenal vessels, particularly afferent arterioles. |
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