|
| Article Access Statistics | | | Viewed | 7954 | | | Printed | 162 | | | Emailed | 9 | | | PDF Downloaded | 0 | | | Comments | [Add] | | |
|
Click on image for details.
|
|
|
|
|
|
| Year : 1985 | Volume
: 31
| Issue : 1 | Page : 5-10 |
Diabetes and the kidney.
Patel JC
How to cite this article:
Patel J C. Diabetes and the kidney. J Postgrad Med 1985;31:5-10 |
The association between diabetes and the renal complications, either vascular or infective, is well-known. The vascular lesion affects the arteries, the arterioles and the capillaries. The capillary lesion is a characteristic one, nodular glomerulosclerosis, commonly known as "Kimmelstiel-Wilson (K.W.) lesion.[2],[5] The infective component includes acute and chronic pyelonephritis. Evidence of urinary tract infection is found more often in diabetics than in non-diabetics.[2],[3],[4] It is more frequent in females. Further, it is difficult to control the infection in a diabetic and recurrences are common. Kidney involvement in diabetes has been described by some Indian workers.[1],[6],[9],[10] In this paper, I wish to describe kidney involvement in a large series of patients.
This is a retrospective analysis of the case records of 4349 diabetics, admitted into the Bombay Hospital, Bombay, during an 8 year period from 1967 to 1974. Of these 4349 cases, 1484 (34.1%) had renal involvement as evidenced by albuminuria. These patients were classified clinically into 4 groups: 1. K.W. syndrome: These patients had hypertension, generalised edema and renal involvement as indicated by the presence of protein, casts and R.B.Cs in their urine with or without pyuria. Majority had raised blood urea. Renal biopsy was not done in any patient. 2. Chronic pyelonephritis (CPN) : These patients had pyuria and pus cell casts. Majority had significant bacteriuria. History of previous acute urinary tract infection (U.T.I.) was present only in some patients. 3. Uremia: These patients had blood urea persistently in excess of 75 mg%, in the absence of starvation and dehydration. 4. Acute urinary tract infection (Acute UTI): These patients had acute urinary symptoms associated with fever and pyuria. Positive urine culture reports were available in some of them. Some of these patients presented themselves with acute U.T.I. symptoms whereas others developed them in the hospital while undergoing treatment for some other ailment. Each group was analysed for age, sex, duration of diabetes and associated diseases. The effect of control of diabetes or otherwise on the mortality in these patients was also analysed.
[Table - 1] shows the sex distribution of diabetics with renal involvement. Males predominated in all groups. This predominance was least marked in the group with acute U.T.I. [Table - 2] shows the age distribution of the entire group of diabetics in this series, the patients with renal involvement as whole, and patients with different types of renal involvement. Acute U.T.I. was the most frequent renal lesion followed by uremia. The "occurrence" of renal involvement in the diabetics [calculated as the number of diabetics with renal involvement (column 6, [Table - 2] as per cent of the total number of diabetics in that age group (column 7, [Table - 2] 1 increased progressively with increasing age (column 8,[Table - 2]. However, the "frequency" of renal involvement (calculated as the number of patients in a given age group as per cent of the total number of patients with renal involvement) seemed to rise progressively upto the age of 60 years and then showed a fall. A similar phenomenon was also seen in all the four subgroups. This is probably because diabetics with serious renal involvement did not survive beyond the age of 60 years.
[Table - 3] shows the duration of diabetes in diabetics with renal involvement in different subgroups. The "occurrence," of diabetes (as described above) rises only after 20 years of duration of diabetes (column 8, [Table - 3], although it is quite significant in lower duration as well. The "frequency" of renal involvement (as defined above) shows a progressive fall with increasing duration of diabetes. This suggests that serious renal involvement significantly shortens life. A similar phenomenon is seen in all the four subgroups.
[Table - 4] shows the associated conditions in patients with renal involvement. Hypertension was the commonest, followed by ischaemic heart disease and cerebrovascular accidents. Diabetic coma was relatively infrequent. Gangrene appeared more frequently in K.W. syndrome than in other groups.
[Table - 5] shows the various causes of death in the 308 patients with renal involvement. In all group, myocardial infarction accounted for the largest number of deaths, followed by terminal renal failure.
[Table - 6] shows the mortality in relation to the treatment and the degree of control. As the table shows, there is a marked difference between the well controlled group and the others.
The prevalence of renal involvement in diabetes depends upon the method of its ascertainment,[3],[8],[11] such as autopsy, clinical evaluation, renal function tests, isotope renogram and renal biopsy. Renal involvement may exist without any diagnostic symptoms or signs, and often with normal renal function tests. Proteinuria is, probably, the best single indicator which should make the treating physician look carefully for other evidence of the existence, type and severity of renal involvement. Autopsy studies have shown a 17-36% prevalence of nodular glomerulosclerosis[3] and 20% prevalence of acute pyelonephritis[3] in diabetics dying in the hospital. Many workers[3],[6],[7],[9],[10],[12],[14] have reported on the frequency of clinical renal involvement in diabetes from a study of hospital records. Rohrer[12] and Lundbaek[3] found pyuria twice as common in women as in men with long term diabetes. Indian workers have also reported on the frequency of renal involvement in diabetes: Patel and Talwalkar[10] and Patel et al[9]-0.3%; Sood and Padmavati[13]-11.7%; Dixit et al[1]-87.6%. Mukherjee et al[6] found K.W. syndrome in 30 of the 250, diabetics. In the present series, 191 out of a total of 4349 diabetics (4.4%) had K.W. syndrome. The unusually high frequency of acute U.T.I. in this series may be due to the inclusion of surgical diabetics such as those with enlarged prostate and acute retention of urine. The predominance of male patients with renal involvement in this series (M: F = 1.64:1) is probably due to the larger number of male admissions to the hospital. However, the M: F ratio of 1.36:1 was lower in the subgroup with acute U.T.I. It is well known that acute U.T.I. is more frequent in women than in men.[5] Hypertension was the most frequent associated condition followed by ischaemic heart disease; diabetic coma was relatively infrequent. Of the 191 patients of K.W. syndrome, only 152 had hypertension; the absence of hypertension in the remaining cases was probably due to associated ischaemic heart disease, electrolyte imbalance, or poor general health. Myocardial infarction was the commonest mode of death, followed by terminal renal failure in this series; infections also accounted for a large number of deaths. Kidney disease was responsible for deaths in 308 out of 4349 diabetics in this series (7.08%). As expected, the mortality was lower in well controlled than in poorly controlled diabetics.
| 1. | Dixit, N. S., Aga, Vinata; Damodaran, V. N., Natarajan, G. and Vaishnav, H.: Renal disease in diabetics. In, "Diabetes in the Tropics". Editor: J. C. Patel, and N. G. Talwalkar, D.A.I. Publishers, Bombay, 1966, pp. 480-488. Quoted by Patel and Talwalkar.[10]  |
| 2. | Kimmelstiel, P. and Wilson, C.: Intercapillary lesions in the glomeruli of the kidney. Amer. J. Pathol., 12: 83-97, 1936. Quoted by Malins.[4] |
| 3. | Lundbaek, K.: "Long-term Diabetes" E. Munksgaard, Copenhagen, 1953. Quoted by Malins.[4] |
| 4. | Malins, J.: Renal disease in diabetes. In, "Clinical Diabetes Mellitus". Chapter 7, Eyre and Sportswood, ELBS and Chapman and Hall, London, 1968, pp. 152-185. |
| 5. | Marble, A., White, P., Bradley, R. F. and Krall, L. P.: "Joslin's Diabetes Mellitus." 11th Edition, Lea and Febiger, Philadelphia, 1971, p. 528. |
| 6. | Mukherjee, A. B., Pandey, G. C., Banerjee, N. and Dasgupta, M. K.: Clinical observations on cardiovascular complications of diabetes mellitus. In, "Diabetes in Tropics". Editors: J. C. Patel and N. G. Talwalkar, D.A.I. Publishers, Bombay, 1966, pp. 329-335. Quoted by Patel and Talwalkar.[10] |
| 7. | O'sullivan. D. J., FitzGerald, M. G., Meynell, M, J. and Malins, J. M.: Urinary tract infections. A comparative study in the diabetic and general populations. Brit. Med. J., 1: 786-788, 1961. |
| 8. | Otto, H., Kienitz, M. and Firuzian, N.: Current concepts of pyelonephritis in diabetes. In, "Diabetes in Tropics". Editors: J. C. Patel and N. G. Talwalkar, D.A.I. Publishers, Bombay, 1966, pp. 474-479, Quoted by Patel and Talwalkar.[10] |
| 9. | Patel, J. C., Dhirawani, M. K. and Juthani, V. J.: Incidence of complications in 5481 cases of diabetes mellitus. In, "Diabetes in Tropics". Editors: J. C. Patel and N. G. Talwalkar, D.A.I. Publishers, Bombay, 1966, pp. 459-465. Quoted, by Patel and Talwalkar.[10] |
| 10. | Patel, J. C. and Talwalkar, N. G.: "Diabetes in the Tropics". Proceedings of the World Congress on Diabetes in the Tropics held under the auspices of the Scientific section of Diabetic Association of India, Bombay, on 20-22, January, 1966, Diabetic Association of India Publishers, 1966. |
| 11. | Robbins, S. L. and Tucker, A. W. Jr.: The cause of death in diabetes. A report of 307 autopsied cases. New Engl. J. Med., 231: 865-868, 1944. Quoted by Malins.[4] |
| 12. | Rohrer, P. A.: Pyuria in the diabetic. J. Urol., 59: 385-389, 1948. Quoted by Malins.[4] |
| 13. | Sood, S. and Padmavati, S.: Complications of diabetes mellitus in women. In, "Diabetes in the Tropics". Editors: J. C. Patel and N. G. Talwalkar, D.A.I. Publishers, Bombay, 1966, pp. 466-473. Quoted by Patel and Talwalkar.[10] |
| 14. | Thomsen, A. C.: "The Kidney in Diabetes Mellitus". E. Munksgaard, Copenhagen, 1965, p. 124. Quoted by Malins.[1] |
 |
 |
|
|
|
|
