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      Prevalence of Nondiabetic Renal Disease in Diabetic Patients

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          Abstract

          Background: Diabetic nephropathy is the leading cause of end-stage renal disease in the USA, yet most patients with type 2 diabetes mellitus are not formally evaluated with a renal biopsy. Our aim was to evaluate the prevalence of nondiabetic renal disease (NDRD) in patients with type 2 diabetes mellitus to determine common clinical indicators suggestive of NDRD. Methods: A retrospective analysis was performed on biopsy reports of patients who had undergone native renal biopsy between January 1, 1995, and December 31, 2005. Results: After exclusion of 57 patients, 233 patients with DM2 were included in our analysis. Mean age at the time of biopsy was 58.1 ± 13.7 years, and 53.0% of the study population were male. There were 124 cases (53.2%) with a pathologic diagnosis of NDRD, 64 (27.5%) with pure diabetic glomerulosclerosis (DGS) and 45 (19.3%) with concurrent NDRD and DGS (CD). Patients with NDRD tended to be younger than those with DGS and had significantly less associated diabetic retinopathy. Focal segmental glomerulosclerosis was the most common lesion found in patients with NDRD and accounted for 21.0% of all NDRD, followed by minimal-change disease (15.3%). IgA nephropathy (15.6%) and membranous glomerulonephritis (13.3%) were the most prevalent lesions found in patients with CD. Conclusions: The high prevalence of NDRD found in our population underscores the need for clinicians to consider renal biopsy in diabetic patients with an atypical clinical course, since additional disease-specific therapies may be helpful for this subset of the population.

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          Most cited references 15

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          Proteinuria reduction and progression to renal failure in patients with type 2 diabetes mellitus and overt nephropathy.

          Little is known of the effects of blood pressure reduction by specific classes of antihypertensive drugs on the association between proteinuria reduction and progression of kidney insufficiency and development of end-stage kidney disease in patients with overt diabetic nephropathy in type 2 diabetes mellitus. Associations between baseline proteinuria and proteinuria reduction by either irbesartan, amlodipine, or control for similar decrements in blood pressure and the cumulative incidence of renal end points were examined using the Kaplan-Meier method in patients enrolled in the Irbesartan Diabetic Nephropathy Trial. Risk for kidney failure doubled for each doubling of baseline proteinuria level (hazard ratio, 2.04; 95% confidence interval, 1.87 to 2.22; P < 0.001). For each halving of proteinuria level between baseline and 12 months with treatment, risk for kidney failure was reduced by more than half (hazard ratio, 0.44; 95% confidence interval, 0.40 to 0.49; P < 0.001). For the same proportional change in proteinuria, the reduction in risk for kidney failure was significantly greater for irbesartan compared with amlodipine ( P = 0.048), but not control ( P = 0.245). Proteinuria reduction in the first 12 months of therapy with irbesartan is associated with 36% of the total renoprotective effect observed. Baseline proteinuria is an important risk factor for kidney failure and provides a means to identify patients at greatest risk. Halving proteinuria halves the kidney risk. Proteinuria reduction using an angiotensin receptor-blocking agent, such as irbesartan, should be regarded as an important therapeutic goal in renoprotective strategies.
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            Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy.

            The risks associated with performing a percutaneous renal biopsy have substantially decreased in the past two decades because of technical advances in the method. However, bleeding complications still occur, resulting in increased hospital stay and treatment costs. We investigated the predictive value of demographics (age, gender), clinical data (blood pressure), baseline chemistry (hemoglobin/hematocrit, prothrombin time, partial thromboplastin time, bleeding time, serum creatinine, daily proteinuria), and needle size for the risk of major (need for blood transfusion, nephrectomy, or angiography) or minor (no need for any intervention) postrenal biopsy bleeding complications. This was a prospective cohort study of 471 patients who underwent ultrasound-guided biopsy of native kidney by automated needle in a single center; all biopsies were performed by two experienced nephrologists. Patients with transplant kidneys were excluded from the study. Predictors of postbiopsy bleeding were assessed by multiple linear and multivariate logistic regression analysis. Data are presented as unadjusted (OR) and adjusted odds ratios (AOR) with 95% confidence intervals (CI). The study cohort consisted of 471 (277 males, 194 females) patients. Of these, 161 (34.1%) experienced postbiopsy bleeding [157 (33.3%) hematomas, 2 (0.4%) gross hematuria, 2 (0.4%) arteriovenous fistula]. Major complications were seen in 6 (1.2%) patients (blood transfusion, N= 2; angiography, N= 3; nephrectomy, N= 1), but no deaths occurred. The risk of postbiopsy bleeding was higher in women (39.7% women, 30.3% men, AOR 2.05, 95% CI 1.26 to 3.31, P= 0.004), younger subjects (35.0 +/- 14.5 years vs. 40.3 + 15.4, AOR 0.80, CI 0.68 to 0.94, P= 0.006), and patients with higher baseline partial thromboplastin time (102.7 + 11.8% vs. 100.1 + 10.0%, AOR 1.26, CI 1.02 to 1.54, P= 0.032). These findings were independent of size of hematoma. Although the methods for performing a percutaneous renal biopsy have improved in the past two decades, renal biopsy is still not a risk-free procedure. Of the data routinely collected for potential predictors of postbiopsy bleeding complications, only gender, age, and baseline partial thromboplastin time show a significant predictive value. The other variables investigated do not have any predictive value.
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              Non diabetic renal disease in type 2 diabetes mellitus.

              The aim of this analysis of renal biopsies in people with type 2 diabetes was to know the prevalence and nature of non-diabetic renal disease (NDRD) and to note its correlation with the duration of diabetes, extent of proteinuria and presence or absence of retinopathy. From January 2000 to December 2004, 160 people with type 2 diabetes with clinically suspected NDRD underwent renal biopsy reported by a single pathologist. The case records of these patients were retrospectively analysed. Based on the biopsy findings, patients were grouped as Group I, isolated NDRD; Group II, NDRD with underlying diabetic glomerulosclerosis; and Group III, isolated diabetic glomerulosclerosis. The relation of histology with clinical profile in each group was noted and statistically analysed using strata 6 software. Of the 160 patients studied, 118 were males and 42 were females (2.8:1). The average age was 51.35 years (30-79). Indications for renal biopsy included: nephrotic syndrome in 55 (34.37%), acute renal failure (ARF) in 49 (30.62%), rapidly progressive renal failure (RPRF) in 24 (15%), absent retinopathy in 19 (11.87%), haematuria in 10 (6.25%) and acute on chronic renal failure (CRF) in three (1.87%) patients. Group I included 68 patients (42.50%), Group II included 48 patients (30%) and Group III included 44 patients (27.50%). The mean duration of diabetes was 5.37, 10.12 and 6.86 years in Groups I, II and III respectively. The duration of diabetes was significantly less in Group I compared with Group II and III combined (5.37 vs 8.53; P < 0.001). Diabetic retinopathy was absent in 61 (38.13%) patients, of whom 41 (67.21%) had isolated NDRD. The most common NDRD were acute interstitial nephritis (18.1%), post infectious glomerulonephritis (17.24%), membranous nephropathy (11.20%) and focal segmental glomerulosclerosis (7.75%). Prevalence of NDRD (either isolated or superimposed on underlying diabetic glomerulosclerosis) is very high in appropriate clinical settings. The shorter duration of diabetes and the absence of retinopathy, especially when associated with nephrotic proteinuria, strongly predict NDRD.
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                Author and article information

                Journal
                AJN
                Am J Nephrol
                10.1159/issn.0250-8095
                American Journal of Nephrology
                S. Karger AG
                0250-8095
                1421-9670
                2007
                May 2007
                09 May 2007
                : 27
                : 3
                : 322-328
                Affiliations
                aKaiser Permanente, Los Angeles Medical Center, Los Angeles, Calif., and bResearch and Evaluation, Southern California Permanente Medical Group, Pasadena, Calif., USA
                Article
                102598 Am J Nephrol 2007;27:322–328
                10.1159/000102598
                17495429
                © 2007 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, Tables: 2, References: 24, Pages: 7
                Categories
                Original Report: Patient-Oriented, Translational Research

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