END STAGE KIDNEY DAMAGE-DM-ESKD
Our body's metabolic and other wastes are excreted out by various means. But a major chunk especially the protein metabolic wastes such as Blood Urea Nitrogens and Creatinin which should be cleaned out 100% from our blood are excreted by kidneys. If kidneys are not functioning properly these deadly poisonous wastes will remain in our blood to produce a fatality.
Kidney damages are of two types such as Acute or reversible and Chronic or irreversible. Chronic Kidney Damages (CKD) and End-Stage Kidney Damages (ESKD) are the major causes of Diabetic mortality.
Chronic and improperly managed hyperglycemia is one of the major causes of nephropathy. Diabetic nephropathy is a leading cause of ESKD.
A nephron is one of the million basic units by which our two kidneys are composed and made of.
The Bowman's Capsule descends downwards to a tubule known as the proximal convoluted tubule (PCT) through which the filtrate passes and subjected to various proportions of reabsorptions and secretions.
The proximal tubule further descends down to a small loop like a narrow U tube known as Loop of Henley which has no activities on the filtrate. The loop again ascends to form the distal convoluted tubule (DCT) in which again there are certain proportions of reabsorptions and secretions on the filtrate.
Finally, the filtrate after subjected to various reabsorptions and secretions to form the final shape to form the urine and will be guided to pass through the collecting duct followed by the ureter which leads to the urinary bladder.
These units are by God's Grace present in each kidney many and many and approximately one million nephrons are present in each kidney. More than a certain proportion of these units if they get damaged irreversibly by some diseases such as DM and Hypertension the result is the ESKD.
Diabetic nephropathy is a slowly progressing disease with no symptoms in the beginning but if unattended properly with longstanding mismanagement of DM the disease progresses to the final stage of ESKD. Fortunately, the progression is slow and may take hardly 10 to 15 years.
The nephropathy is caused by the damages in the glomerular filter barrier (GFB) a fine meshwork of small tiny blood vessels to carry blood. Diabetes mainly damages these tiny blood vessels by improper glucose metabolism and by forming toxic active oxidative products. It is classified as small blood vessel complications of diabetes.
Signs and Symptoms
During its early course, the nephropathy is mostly asymptomatic. As the disease progress slowly and the symptoms appear after 10 to 15 years when the progression attains ESKD.These ESKD symptoms are as follows:-
1.Tiredness
2.Headaches
3.General feelings of illness
4.Nausea and Vomiting
5.Frequent urine
6.Lack of hungry
7.Itchy skin
8.Leg swelling.
If anyone of the above symptoms are present please check for albuminuria, BUN, and creatinine.
Major Causes
1.Long-standing Diabetes Mellitus (especially type-1.)
2.Long-standing Hypertension
3.Heavy smoking
4.Family history of kidney problems
Mechanism
Diabetes causes an imbalance of glucose metabolism and damage blood vessels by producing toxic oxidative chemicals.
As we already knew the head of the nephrons is composed of a fine blood filtering meshwork made out of tiny blood vessels known as Glomerular Filter Barrier (GFB) which will allow only water and small molecules through the meshwork to be filtered off by leaving large protein molecules like albumin, and microalbumin, and lipids to stay in the blood itself.
As nephropathy progresses this glomeruli meshwork also progressively undergo damages and the filter processes become improper by tearing off the meshwork so that albumin and other large molecules also will be filtered off.
Diagnosis
1. Albumin and microalbumin tests in the urine may show their presence (Normal value for albumin is <30mg/24 hrs;
The normal range for microalbumin is 30 -299 mg/24 hrs)
If clinically the total albumin presence exceeds 300mg/24 hrs then it is concluded that there is nephropathy.
People with DM are recommended to undergo the albumin test in the urine annually with an immediate beginning of test if diagnosed positively for type-2 diabetes because the onset of the disease is not well established in the beginning, and begin after five years in case of type-1 diabetes.
To test the kidney function the established glomerular filter rate (eGFR) should be measured by the 24-hour collection of urine.
The normal range is 90 - 120ml/min/1.73square meter
Treatments
The aim of the treatment is to slow down the disease progression and to reduce the related complications
The drugs of choice are the hypertensive group of medicines the Angiotensin Converter Enzyme Inhibitors such as enalapril, captopril, and benazepril.
Angiotensin-II is a polypeptide that playing an important role in regulating total peripheral resistance(TPR) and altering kidney functions.
Renin an enzyme secreted by the kidneys acts on a kind of plasma protein the angiotensinogen when blood enters into the glomeruli to form angiotensin-I. Another enzyme is known as angiotensin-converting enzyme acts on it and converting it into angiotensin-II. This is the active form of regulating kidney functions. It causes in distal tubule to increase the reabsorption of sodium with the exchange of potassium through a hormone known as vasopressin so that more concentrated urine formed.
ACE inhibitors prevent the formation of this substrate and alter the process by eliminating more sodium out and ease the blood pressure and protect the kidney to function normally.
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