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Renal Involvement in Systemic Conditions (3 types of involvement (Renal…

- - - - It is a less reliable predictor of nephropathy in older patients with type 2 diabetes, in whom it may be accounted for by other diseases, although it is a potentially useful marker of an increased risk of macrovascular disease. Nevertheless, progressively increasing albuminuria, or albuminuria accompanied by hypertension, is most likely to be due to early diabetic nephropathy
    - - Type 1 diabetes, ACE Inhibitor Type 2: Angiotensin 2 receptor blocker (ARB)
        
        Problems with the use of either in diabetic nephropathy because of hyperkalaemia (p. 440) and renal artery stenosis (p. 496).
        Non-dihydropyridine calcium antagonists (diltiazem, verapamil). may be suitable alternatives.
        
        Diabetic control becomes difficult as renal impairment
        progresses. Treatment with metformin should be
        withdrawn when creatinine is higher than 150 μmol/L (1.7 mg/dL), as the risk of lactic acidosis is increased.
        Long-acting sulphonylureas should be replaced by short acting
        agents that are metabolised rather than excreted.
        Renal replacement therapy (p. 492) may benefit diabetic
        patients at an earlier stage than other patients
        with ESRF, although it may carry additional difficulties.
        Renal transplantation can dramatically improve the
        life of many, and any recurrence of diabetic nephropathy
        in the allograft is usually too slow to be a serious
        problem, but associated macrovascular and microvascular
        disease elsewhere may still progress. Pancreatic
        transplantation (generally carried out at the same time
        as renal transplantation) can produce insulin independence
        and slow or reverse microvascular disease, but
        the supply of organs is very limited and this is available
        to few. For further information on management,
        see Chapter 17.
- - - - Type 2 hepatorenal syndrome usually occurs in patients with refractory ascites, is characterized by a moderate and stable increase in serum creatinine, and has a better prognosis.