GLOMERULONEPHRITIS IN TYPE 2 DIABETES MELLITUS MOHAN DAS

GLOMERULONEPHRITIS IN TYPE 2 DIABETES MELLITUS MOHAN DAS M. K, JACOB GEORGE, VIMALA. A. DEPARTMENT OF NEPHROLOGY, MEDICAL COLLEGE, THIRUVANANTHAPURAM 1

BACKGROUND • INCREASING INCIDENCE OF NON DIABETIC RENAL DISEASE AS A CAUSE OF ACUTE RENAL FAILURE IN TYPE 2 DIABETES MELLITUS. • SPECIFIC TREATMENT ALTERS OUTCOME. 2

OBJECTIVES • INCIDENCE AND CLINICAL PROFILE OF NON DIABETIC RENAL DISEASE IN TYPE 2 DIABETES MELLITUS • RENAL HISTOLOGY • IDENTIFY NATURE OF GLOMERULAR DISEASE • PROGNOSTIC FACTORS • RESPONSE TO SPECIFIC TREATMENT 3

PATIENTS&METHODS • PERIOD OF STUDY JUNE 1, 2001 -DEC 31, 2004 INCLUSION CRITERIA 4 • PATIENTS WITH TYPE 2 DIABETES MELLITUS AND ANY ONE OF THE FOLLOWING 1. ANTECEDENT INFECTION. 2. MICROSCOPIC OR MACROSCOPIC HAEMATURIA WITH NEGATIVE URINE CULTURE. 3. DISPROPORTIONATE DECLINE IN GFR. 4. . LOW C 3. 5. ABSENCE OF DIABETIC RETINOPATHY.

PATIENTS&METHODS(CONT. ) • GFR IS CALCULATED USING COCKROFT AND GAULT FORMULA • DISPROPOTIONATE DECLINE IN GFR DEFINED AS DECREASE IN GFR MORE THAN 10 ml/year 5

EXCLUSION CRITERIA 1. PATIENTS WITH CARDIAC FAILURE. 2. PATIENTS WITH ISCHAEMIC NEPHROPATHY. 3. IDENTIFIED PRECIPITATING FACTORS FOR DETERIORATION OF GFR LIKE DRUGS, HYPOVOLEMIA. 6

RESULTS • • 7 TOTAL NUMBER OF PATIENTS -24 MEAN AGE OF PRESENTATION-51 MALE TO FEMALE RATIO -13: 11 MEAN DURATION OF DIABETES-8 yrs MEAN DURATION OF HYPERTENSION-5 yrs MEAN BLOOD PRESSURE -150/100 mm. Hg ALL PATIENTS HAD NON NEPHROTIC RANGE PROTEINURIA WITH A MAXIMUM OF 2. 8 gms.

CLINICAL PROFILE OF POST INFECTIOUS CRESCENTIC GN Mean age 51. 6 M: F 4: 1 Mean MAP 103 Mean duration of DM 10 Oliguria 100% Pyoderma 100% Low C 3 35 3/5

CLINICAL PROFILE OF POST INFECTIOUS CRESCENTIC GN Dialysis requiring RF 100% Underlying diabetic nephropathy 100% TIN Type of crescents Mortality 36 2/5 Cellular 2 Fibrocellular 3 100%

CLINICAL PROFILE OF DPGN WITHOUT CRESCENTS Character Survived Death Mean age 53. 6 57. 3 M: F 2: 1 95. 6% 99. 6% 10 16 Oliguria 100% Pyoderma 66% 100% 1/1 Mean MAP Mean duration of DM Low C 3 37

CLINICAL PROFILE OF DPGN WITHOUT CRESCENTS Dialysis requiring 66. 6% 100% 1/3 33% 3. 8 7. 1 RF Underlying diabetic nephropathy TIN Mean Serum Creatinine 38

CLINICAL PROFILE OF Ig. A Mean age 48. 6 M: F 1: 2 Mean MAP Mean duration of DM 39 97. 6% 4. 3 Oliguria 66. 6% Pyoderma 66. 6% Dialysis requiring RF 66. 6%

CLINICAL PROFILE OF Ig. A Underlying diabetic nephropathy TIN Mean Serum Creatinine 33% 6 Crescents 1/3 Total No. of Patients 3/24 Survival 40 1/3 100%

CLINICAL PROFILE OF MGN, MPGN AND LN Character MGN (2/18) MPGN (1/18) LN(1/18) Mean age 55 73 41 M: F 2: 0 1: 0 Mean MAP 91. 5 106 103 Mean duration 2. 5 2 8 Oliguria 100% Dialysis 1/2 0 0 of DM requiring RF 41

CLINICAL PROFILE OF MGN, MPGN AND LN Character MGN (2/18) MPGN (1/18) LN(1/18) 1/2 1/1 0/1 TIN NIL 1/1 0/1 Mean Serum 4. 3 1. 4 2. 3 ½ 0/1 100% Underlying diabetic nephropathy Creatinine Crescents Survival 42

CLINICAL PROFILE OF PATIENTS WITH DN ALONE Character Survived Death Mean age 47 43 M: F 1: 1 0: 2 101. 6 105 6. 2 4. 5 100% Dialysis requiring RF 0% 100% TIN 33% 3 5 Mean MAP Mean Duration of DM Oliguria Mean Serum Creatinine 43

CLINICAL PROFILE OF PATIENTS WITH TIN AND TIN+DN Character TIN (1/24) TIN+DN (1/24) Mean age 46 47 M: F 1: 0 0: 1 Mean MAP 91 92 Mean Duration of DM 4 8 Oliguria 0% 100% Dialysis requiring RF 0% 100% Mean Serum Creatinine 2. 7 12 100% 0% Survival 44

STATISTICAL ANALYSISGN IN TYPE 2 DM • Mean value for oliguria and pyoderma in survived group was 0. 615 and 0. 538 respectively and in expired group 1. 00 and 1. 00 • Standard error was 0. 14 and 0. 143 in survived group and 0. 00 in expired group. • p-value was 0. 018 and 0. 008 in survived group and 0. 02 and 0. 008 in expired group • Statistically significant. 45

GN IN TYPE 2 DIABETES MELLITUS Variables Group Code Duration of DM 1 2 11 13 10. 727 7. 0769 2. 33 1. 51 0. 191 0. 207 MAP 1 2 11 13 104. 83 100. 75 2. 07 2. 27 0. 205 0. 198 Duration of HTN 1 2 11 13 1. 39 1. 15 0. 375 0. 38 46 No Mean 5. 54 3. 92 Std. Error Mean p. value

GN IN TYPE 2 DIABETES MELLITUS Variables Group Code No Mean 24 hr Urine Protein 1 2 11 13 Oliguria 1 2 11 13 1 0. 615 Pyoderma 1 2 11 13 1 Serum Creatinine 1 2 11 13 6. 37 47 Std. Error Mean 1229. 1 1215. 8 124. 8 p. value 216. 3 0. 96 0. 958 0 0. 14 0. 02 0. 018 0. 5385 0 0. 143 0. 008 4. 007 0. 656 0. 354 0. 003 0. 006

STATISTICAL ANALYSIS DPGN IN TYPE 2 DM • No variables are found to be statistically significant. • May be because of small sample size. 49

DPGN IN TYPE 2 DM Variables Group Code Age 1 2 8 3 53. 75 53. 66 Duration of DM 1 2 8 3 12. 62 10 2. 94 3. 6 MAP 1 2 8 3 105. 81 108. 86 2. 79 5. 56 0. 601 0. 657 Duration of HTN 1 2 8 3 7 5. 33 1. 62 2. 33 0. 596 0. 588 50 No. Std. Error Mean p. value 3. 266 3. 48 0. 989 0. 987 0. 636 0. 598

DPGN IN TYPE 2 DM Variables Group Code 24 hr Urine Protein 1 2 8 3 1140 726. 66 161. 2 136. 7 0. 178 0. 089 Pyoderma 1 2 8 3 1 0. 666 0 0. 333 0. 104 0. 423 Serum Creatinine 1 2 8 3 6. 125 4. 6 0. 3895 0. 665 0. 07 0. 13 1 2 8 3 1 0. 333 0. 006 0. 184 Dialysis requiring renal failure 50 No Mean Std. Error Mean 0 0. 333 p. value