Nonproteinuric Diabetic Kidney Disease in Elderly

Mennat Allah Abdel Ghany Shawkat Mohammed


Elderly individuals are a fast growing subgroup of the general population, and diabetes mellitus is now a major health issue affecting them. Chronic kidney disease (CKD) complicates diabetes and also has an increased prevalence in elderly individuals. Particularly in those older than 60 years, the most common cause of CKD and end-stage renal disease is diabetic kidney disease. A third of new ESRD cases in people older than 75 years are caused by diabetic nephropathy (DN). The time of onset of DM2 (Type II Diabetes Mellitus) is rarely known accurately, and cardiovascular events in a patient with DM2 can censor the natural history of DN. A feature of the natural history of DN that is gaining renewed investigation is the progression from normoalbuminuria to proteinuria and then to renal failure. In the classical paradigm, overt proteinuria precedes the decline in renal function. Recently, there have been several reports describing patients with primarily DM2 and presumed DN who have declining renal function with normoalbuminuria or microalbuminuria and not the previously well-described proteinuria. The objectives of this thesis are to compare the kidney functions and renal vascular resistance and the associated cardiovascular risk factors in proteinuric and nonproteinuric diabetic nephropathic patients. This study was a two stage study: the first stage was observational cross-sectional in which 500 elderly diabetic patients were included from the inpatient wards and outpatient clinics of geriatric medicine and internal medicine departments of Ain Shams University hospitals. The second stage was comparative between nonproteinuric nephropathic patients and their matched proteinuric nephropathic patients.Twenty more participants were recruited to clarify the significance of the renal resistance index. Each patient underwent comprehensive geriatric assessment including full clinical examination and laboratory assessment to determine nephropathy and its risk factors, diabetes complications, cardiovascular disease and cardiovascular risk factors. This assessment included: • Framingham 10 Year Risk of General Cardiovascular Disease • CRP assay, serum Creatinine, Uric acid, Total bilirubin, lipid profile, protein/creatinine ratio, 24 hrs urinary protein. • Abdominopelvic ultrasound with Doppler sonographic examination of the kidneys. Assessment was carried out on admission. Any patient with known kidney disease, urinary tract infections, hepatitis C using drugs affecting kidney functions as diuretics or abnormal blood urea or high creatinine was excluded from the study. Our study revealed that There is a high prevalence of diabetic nephropathy with the majority of patients in stage 2-3 and similar prevalence of nonproteinuric and proteinuric nephropathy in early stages. Among the risk factors studied only age, gender and vitamin D use showed significant value, while neither smoking habits, duration of diabetes, diabetes control, insulin use, ACEi or ARBs use, statins use nor weight showed any significant difference. When studying cardiovascular complications we found no statistically significant difference in the frequency of ischemic heart disease events between proteinuric and nonproteinurics, although most of the participants had a previous ischemic cardiac event, also for heart failure and stroke both groups presented no significant difference. But when we studied peripheral arterial disease, proteinuric patients suffered from more peripheral arterial disease significantly specially in the first stage of intermittent claudication. When we studied the relation between proteinuria and risk factors for cardiovascular diseases we found that: There was no significant difference between proteinurics and nonproteinurics in the levels of HDL-cholesterol and LDL-cholesterol. Also there was no significant difference when we calculated the Framingham 10 year overall risk score. Nonproteinuria was associated with increased renal resistance index indicating nephropathy though this relation was not statistically significant. It showed significance only after using a less cutoff point. Renal resistance index was inversely correlated with glomerular filtration rate after adjusting ideal body weight. A scoring system, including age, persistent microalbuminuria, diabetes duration and control association with hypertension and rise of RRI, is needed to diagnose diabetic nephropathy early and accurately to implement secondary preventive measu

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Other Titles اعتلال الكلى السكري بدون تسرب الزلال في البول في المسنين
Issue Date 2016

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