Prevalence of non-diabetic renal disease in patients with type 2 diabetes

doi:10.1016/j.diabres.2009.11.012

Diabetes Research and Clinical Practice

Volume 87, Issue 3, March 2010, Pages 354-359

https://doi.org/10.1016/j.diabres.2009.11.012 Get rights and content

Abstract

It is important to differentiate proteinuria from non-diabetic renal diseases (NDRD) or diabetic nephropathy in diabetic patients. The purpose of our study was to evaluate the prevalence of NDRD. A retrospective analysis was performed on diabetic patients who had undergone renal biopsy during a 6-year period. Our study revealed a high prevalence of NDRD in the diabetic population. Sixty-nine patients were investigated, 52.2% were diagnosed as NDRD and 47.8% as DN. Focal segmental glomerulosclerosis was the most common lesion found in patients with NDRD. We found a relationship between DN and fasting blood glucose level, systolic blood pressure, diastolic blood pressure, LVMI, intima-media thickening (IMT), and the presence of carotid plaques. Patients with NDRD had a lower incidence of diabetic retinopathy (DR). The absence of DR to differentiate NDRD had a sensitivity of 72.7%, a specificity 91.7%, and an ROC = 0.822. Fasting blood glucose level had a sensitivity and specificity of 93.9% and 75%, respectively. Similarly, the use of IMT had sensitivity and specificity of 90% and 75.8%, respectively. In this study, we determined that the absence of DR, a lower fasting blood glucose level, and IMT is useful in differentiating NDRD from DN in diabetic patients with overt proteinuria.

Introduction

Proteinuria in diabetic patients is usually considered to be indicative of diabetic nephropathy (DN) [1]. DN is characterized by persistent proteinuria, hypertension and a progressive decline in renal function. It accounts for over 40% of new cases of end-stage renal disease (ESRD) annually, and it is considered to be the leading cause of ESRD in the USA, Europe, and Japan [2]. In China, DN is believed to be the second most common cause of ESRD. However, non-diabetic renal disease (NDRD) is also a common finding in patients with type 2 diabetes mellitus. The frequency of concurrent NDRD found on renal biopsy has been reported to be from 7% to 44% [3]. Clinical indicators of NDRD include rapid deterioration of renal function, microscopic or macroscopic hematuria, and proteinuria without diabetic neuropathy or retinopathy [4], [5]. The therapeutic decisions based on the results of the biopsy may be different. Identification of diabetic patients at high risk of NDRD earlier could help in delaying the decline in their renal function.

The aim of our study was to evaluate the prevalence of NDRD in patients with diabetes mellitus and to determine common clinical predictors of NDRD. This information will assist clinicians to evaluate NDRD and may lead to more effective medical management for these patients.

Section snippets

Patients and data collection

All the patients came from Renji Hospital, Shanghai Jiaotong University School of Medicine. We performed a retrospective data analysis.

From Chinese DM patients with renal involvement referred to our division. 69 patients with proteinuria over 1 g or GFR < 60 ml/min were enrolled in the present study. All patients were over 18 years old, and had a history of type 2 diabetes mellitus. The patients agreed to a biopsy. All patients in the study had kidneys of normal size and structure. We excluded

Results

69 patients with type 2 diabetes mellitus were enrolled in this study. Males accounted for 52.2% of the study population. Of the 69 patients, 36 (52.2%) had a pathologic diagnosis of NDRD and 33 (47.8%) had pure DN. The age of the patient at the time of biopsy was 53.07 ± 7.48 years. Serum creatinine was 118.81 ± 52.02 μmmol/L, and GFR was 57.86 ± 27.10 ml/min/1.73 m². Urinary protein excretion was 3.47 ± 2.74 g/day. Patient demographics are summarized in Table 1.

Patients with only NDRD tended to be

Discussion

Proteinuria in diabetic patients is usually interpreted as diabetic nephropathy [1]. In contrast, accumulated clinical data suggest non-diabetic renal disease (NDRD) is also a common finding in patients with type 2 diabetes mellitus [3], [5], [8]. To evaluate the prevalence of NDRD in patients with type 2 diabetes, we analyzed our kidney biopsy in proteinuric patients with type 2 diabetes. Our findings demonstrated that these patients underwent renal biopsy in our hospital showed high rates

Conflict of interest

The authors state that they have no conflict of interest.

Acknowledgements

We would like to thank the doctors of Renal Divison, Renji Hospital Shanghai Jiaotong University School of Medicine for their works. This work was supported in part by grants [2008] No. 49 and 09dZ1973600 from Shanghai PuDong Society Development Burean, Science and Technology Commission of Shanghai Municipality, China.

References (20)

R. Kikkawa et al.
Progression of diabetic nephropathy
Am. J. Kidney Dis.
(2003)
B.S. Kasinath et al.
Nondiabetic renal disease in patients with diabetes mellitus
Am. J. Med.
(1983)
American Diabetes Association, Diabetic nephropathy, Diabetes Care 25 (2002)...
T.T. Pham et al.
Prevalence of nondiabetic renal disease in diabetic patients
Am. J. Nephrol.
(2007)
A. Sessa
IgA nephropathy complicating diabetic glomerulosclerosis
Nephron
(1998)
S.E. Ukowska et al.
Renal affection in patients with diabetes mellitus is not always caused by diabetic nephropathy
Acad. Med. Bialost.
(2004)
A.S. Levey
A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group
Ann. Intern. Med.
(1999)
R.A. Cohen et al.
Clinical practice. Microscopic hematuria
N. Engl. J. Med.
(2003)
T.Y. Wong et al.
Renal outcome in type 2 diabetic patients with or without coexisting nondiabetic nephropathies
Diabetes Care
(2002)
S. Olsen et al.
How often is NIDDM complicated with non-diabetic renal disease? An analysis of renal biopsies and the literature
Diabetologia
(1996)

There are more references available in the full text version of this article.

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Clinical characteristics of diabetic nephropathy in patients with type 2 diabetic mellitus manifesting heavy proteinuria: A retrospective analysis of 220 cases
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To determine the predictability of diagnosing diabetic nephropathy (DN) versus non-diabetic renal disease (NDRD) from clinical and laboratory data in Chinese patients with type 2 diabetes mellitus (T2DM) manifesting heavy proteinuria.
We retrospectively analyzed the clinical and laboratory data of patients with T2DM manifesting heavy proteinuria who underwent renal biopsy from January 2014 to December 2017.
According to renal biopsy, 220 patients were finally enrolled, including 109 cases diagnosed with DN alone (49.55%), 94 with NDRD alone (42.73%) and 17 with DN plus superimposed NDRD (7.73%). Multivariate analysis showed the significant risk factors for DN alone were age, duration of diabetes, presence of retinopathy, 24-h proteinuria, serum albumin and SBP. Presence of retinopathy achieved the highest overall diagnostic efficiency with the area under the curve of 0.852, sensitivity of 78.9% and specificity of 91.5%. The combined diagnosis with four indicators (duration of diabetes, retinopathy, SBP, and serum albumin) showed the area under the curve of 0.938, sensitivity of 88.1% and specificity of 87.2%.
The prevalence of DN is high in patients with T2DM manifesting heavy proteinuria. Renal biopsy should be performed in diabetics in the atypical clinical scenario.
Meta-Analysis of Diagnostic Accuracy of Retinopathy for the Detection of Diabetic Kidney Disease in Adults With Type 2 Diabetes
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Citation Excerpt :
In 10 studies, renal biopsy was performed based on differing degrees of proteinuria (4,26,39,44,54,58–62); others (41 studies) were based on clinical suspicion of NDRD, including absence of diabetic retinopathy, abrupt increase in serum creatinine or proteinuria, rapid worsening of renal function and unexplained microscopic hematuria (3,5,6,9,10,18–25,27–38,40–43,45–53,55–57). Of the studies, 30 (3,4,6,9,10,19–22,26,31,34,36–39,41,43,44,47,48,51,52,56–62) reported differing methods used to evaluate DR, such as ophthalmoscopy with or without mydriasis, fluorescein angiography and ophthalmoscopy/fundoscopy and fluorescein angiography, and 21 studies (5,18,23–25,27–30,32,33,35,40,42,45,46,49,50,53–55) did not provide relevant details. The quality of included studies in our meta-analysis was assessed by Quality Assessment of Diagnostic Accuracy Studies-2 (Supplementary Table 1), and the majority of the studies were ranked as having moderately high quality.
The study aimed to explore whether diabetic retinopathy (DR) could distinguish diabetic kidney disease (DKD) from nondiabetic renal diseases (NDRDs) in patients with type 2 diabetes mellitus and renal disease.
We searched PubMed, Embase, Cochrane, MEDLINE and China National Knowledge Internet for articles that enrolled patients with DKD and NDRD. The results were summarized as sensitivity, specificity and the area under the curve of summary receiver operating characteristic curve with their 95% confidence intervals (CIs).
A total of 51 studies that included 4,990 participants were collected for evaluation. The overall pooled sensitivity, specificity and area under the curve with their 95% CIs were 0.67 (95% CI 0.61, 0.73), 0.77 (95% CI 0.72, 0.81) and 0.78 (95% CI 0.75 to 0.82), respectively. If the test for DR is negative, the probability of DKD would decrease to 10%, but if the test for DR is positive, the probability would increase only to 42%. In addition, although the mean specificity of proliferative DR for detection of DKD was 0.98 (95% CI 0.92 to 1.00), the mean sensitivity was 0.25 (95% CI 0.16, 0.35).
DR may lack adequate evidence either to verify DKD or to exclude NDRD, and the severity of DR may not parallel the presence of DKD.
L'étude visait à déterminer si la rétinopathie diabétique (RD) pouvait distinguer la néphropathie diabétique (ND) des néphropathies non diabétiques (NND) chez les patients atteints de diabète sucré de type 2 et de maladie rénale.
Nous avons effectué des recherches dans PubMed, Embase, Cochrane, MEDLINE et China National Knowledge Internet pour trouver des articles sur les patients atteints de ND et de NND. Les résultats ont été résumés selon la sensibilité, la spécificité et l'aire sous la courbe de la fonction d'efficacité du récepteur avec leurs intervalles de confiance (IC) à 95 %.
Un total de 51 études comprenant 4,990 participants ont été recueillies aux fins d'évaluation. L'ensemble des données regroupées concernant la sensibilité, la spécificité et l'aire sous la courbe avec leurs IC à 95 % étaient respectivement de 0.67 (IC à 95 %: 0.61, 0.73), 0.77 (IC à 95 %: 0.72, 0.81) et 0.78 (IC à 95 %: 0.75 à 0.82). Si le test de détection de la RD est négatif, la probabilité de ND diminuerait à 10 %, mais si le test de RD est positif, la probabilité augmenterait seulement à 42 %. De plus, bien que la spécificité moyenne de la DR proliférative pour la détection de la ND était de 0.98 (IC à 95 %: 0.92 à 1.00), la sensibilité moyenne était de 0.25 (IC à 95 %: 0.16 à 0.35).
La RD peut manquer de preuves adéquates pour valider la ND ou pour exclure la NND, et la gravité de la RD peut ne pas correspondre à la présence de ND.
Validation of the 2007 kidney disease outcomes quality initiative clinical practice guideline for the diagnosis of diabetic nephropathy and nondiabetic renal disease in Chinese patients
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Diabetes mellitus (DM) has overtaken infection and immunological factors as the most common cause of end-stage renal disease. The 2007 Kidney Disease Outcomes Quality Initiative (KDOQI) guideline is a widely accepted guideline for the clinical diagnosis of diabetic nephropathy (DN) and non-diabetic renal disease (NDRD). Our study sought to verify its diagnostic ability in the Chinese population.
We included 773 patients with DM who underwent a renal biopsy at the Chinese PLA General Hospital from 2007 to 2016. All patients were divided into three groups according to their pathological findings: isolated DN, isolated NDRD, and DN combined with NDRD.
Good sensitivity and poor specificity were found for the prediction of NDRD in the Chinese population. Rapidly decreasing estimated glomerular filtration rate, systemic disease, refractory hypertension, and the existence of “grey area” patients may have contributed to the poor diagnostic ability.
The diagnostic ability of the 2007 KDOQI guideline for DN and NDRD was unsatisfactory. The high sensitivity and low specificity of the guideline made it more suitable as screening criteria rather than as diagnostic criteria.
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Prevalence of non-diabetic renal disease in patients with type 2 diabetes

Abstract

Introduction

Section snippets

Patients and data collection

Results

Discussion

Conflict of interest

Acknowledgements

Am. J. Kidney Dis.

Am. J. Med.

Prevalence of nondiabetic renal disease in diabetic patients

Am. J. Nephrol.

IgA nephropathy complicating diabetic glomerulosclerosis

Nephron

Renal affection in patients with diabetes mellitus is not always caused by diabetic nephropathy

Acad. Med. Bialost.

A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group

Ann. Intern. Med.

Clinical practice. Microscopic hematuria

N. Engl. J. Med.

Renal outcome in type 2 diabetic patients with or without coexisting nondiabetic nephropathies

Diabetes Care

How often is NIDDM complicated with non-diabetic renal disease? An analysis of renal biopsies and the literature

Diabetologia