Infectious complications in patients with "sweet sickness" are very common. It is necessary to quickly begin active antimicrobial therapy for the timely elimination of the pathological focus. Many patients are interested in what antibiotics can be used for diabetes.
It should be clarified right away that taking this group of medicines should be carried out only under the supervision of the attending physician and with his appointment. alters the normal metabolic process. In most cases, the effect of the drug may differ from that in a relatively healthy body.
Few people know about such nuances. Therefore, undesirable side reactions often appear after using antimicrobial agents for "sweet ailment".
Antibiotics and diabetes
Before the direct use of drugs, it is necessary to study all the risks that may lie in wait for the patient when using drugs.
These include:
- Decompensated course of the disease.
- Elderly age.
- Already formed late (micro- and macroangiopathy, retinopathy, nephro- and neuropathy).
- Duration of the disease (˃10 years).
- The presence of changes in the work of some components of the immune system and the whole organism as a whole (decreased activity of neutrophils, phagocytosis and chemotaxis).
When the doctor takes into account all these aspects, he will be able to more accurately establish the drug necessary for the patient and prevent a number of undesirable consequences.
Also, one should not forget about the following important points:
- Different antibiotics for diabetes mellitus have different effects on the effectiveness of hypoglycemic medications (and tablets that lower serum glucose). So, sulfonamides and macrolides inhibit enzymes that are responsible for the breakdown of active substances of drugs. As a result, more active compounds enter the bloodstream, and the effect and duration of their work increases. Rifampicin, on the contrary, inhibits the quality of the effect of hypoglycemic drugs.
- Microangiopathy leads to small vessel sclerosis. Therefore, it is advisable to start antibiotic therapy with intravenous injections, and not with injections into the muscles, as usual. Only after saturation of the body with the required dose can one switch to oral forms of medication.
When to use antibiotics?
Microorganisms can potentially infect virtually all areas of the body.
The most commonly affected:
- Urinary system;
- Skin integuments;
- Lower respiratory tract.
Urinary tract infections (UTIs) are caused by the formation of nephropathy. The renal barrier does not cope with its function by 100% and bacteria actively attack the structures of this system.
Examples of UTI:
- Perineal adipose tissue abscess;
- Pyelonephritis;
- Papillary necrosis;
- Cystitis.
Antibiotics for diabetes mellitus in this case are attributed to the following principles:
- The drug should have a broad spectrum of action for initial empiric therapy. Until the exact pathogen has been identified, cephalosporins and fluoroquinolones are used.
- The duration of treatment for complex forms of UTI is approximately 2 times longer than usual. Cystitis - 7-8 days, pyelonephritis - 3 weeks.
- If the patient's nephropathy progresses, it is necessary to constantly monitor the excretory function of the kidneys. For this, creatinine clearance and glomerular filtration rate are regularly measured.
- If there is no effect from the antibiotic used, you need to change it.
Skin and soft tissue infections
Such a lesion most often manifests itself in the form of:
- Furunculosis;
- Carbuncle;
- Diabetic foot syndrome;
- Fasciitis.
First of all, to eliminate symptoms, it is necessary to normalize glycemia. It is the increased blood sugar that causes the progression of the disease and slows down the process of soft tissue regeneration.
Additional principles of therapy remain:
- Ensuring complete rest and maximum unloading of the injured limb (when it comes to diabetic foot).
- Use of powerful antimicrobial drugs. The most commonly prescribed cephalosporins of the 3rd generation, carbapenems, protected penicillins. The choice of medication depends on the sensitivity of the pathogen and the individual characteristics of the patient. The duration of the course of treatment is at least 14 days.
- The use of surgical procedures (removal of dead tissue or drainage of purulent foci).
- Continuous monitoring of vital signs. With the active spread of the process, the question of removing the limb may arise.
Respiratory tract infections
Antibiotics for concomitant pneumonia or bronchitis are prescribed according to the standard scheme of the unified clinical protocol. You should start with protected penicillins (Amoxiclav), further according to the situation. It is important to constantly monitor the condition of the lungs by x-ray. Additional symptomatic therapy is used.
Prescribing antibacterial drugs for diabetes mellitus requires great attention and care from the doctor. Since microbes always actively attack the human body with "sweet illness", it is worth considering the use of a variety of probiotics and drugs that prevent the death of their own microflora.
With this approach, it will be possible to neutralize the side effects of most aggressive drugs.
Diabetic nephropathy is one of the most difficult to treat and dangerous complications of diabetes mellitus. Very often, at the beginning of the development of pathology, the symptoms are mild. Therefore, it is extremely important to be able to timely identify the first signs of the disease and ensure the correct treatment of a patient with diabetes mellitus.
Diabetic nephropathy is a pathology of the kidneys, organs of vision and the nervous system that occurs with advanced type 1 and 2 diabetes. In general, the complication develops as a result of damage to the blood vessels, against the background of disturbances in the work of the endocrine system. Diabetic nephropathy can develop in both adults and children. But most often this pathology appears in men, as well as in patients with type 1 diabetes mellitus, which developed in adolescence and puberty.
The pathogenesis of diabetic nephropathy directly depends on the following factors:
- The duration of the development of diabetes mellitus in the patient;
- Difficulties in the violation of carbohydrate metabolism in the body;
- Hereditary factors;
- The presence of high blood pressure in a diabetic and problems with the work of the cardiovascular system.
Also, the development of complications of diabetes mellitus is promoted by infections of the genitourinary system, overweight, smoking.
The main factor contributing to the development of pathology is an increased blood sugar level. So with frequent jumps in glucose levels, a restructuring of the body's biochemical processes occurs. In the body, glycation, or non-enzymatic glycolysis of the protein structures of the blood and renal glomeruli occurs. During this process, carbohydrates ingested with food combine with protein molecules. This contributes to the blockage of blood vessels with further damage.
Particularly large vascular damage occurs in the nephron. This part of the kidney contains many capillary glomeruli, which are the first to be damaged during the development of glycation. Blood pressure rises significantly inside the glomeruli. Then the phenomenon of hyperfiltration occurs, in which primary urine is produced at an accelerated rate, actively flushing proteins from the body.
In the process of hyperfiltration of the renal glomeruli, the fibers of which they are composed are replaced by connective ones. Because of this, there is a decrease in the level of filtration of the kidneys and occlusion of the glomeruli. Ultimately, chronic renal failure develops.
Common Symptoms
In terms of the rate of its development, the disease is classified as slowly progressing. In this case, the symptomatic picture of the disease depends on what stage of development the pathology is at.
For a long time since the onset of complications, diabetic nephropathy does not have any external signs. In this case, it can be observed:
- Increased renal glomeruli;
- Acceleration of glomerular filtration processes;
- Increased blood flow and pressure in the kidney.
The first structural changes in the tissues of the renal glomeruli can be observed 3-5 years after the onset of diabetes mellitus. At the same time, the amount of albumin excreted in the urine does not deviate from the norm and is less than 30 mg / day.
After 5 years from the onset of the development of complications, microalbuminuria is regularly observed in the morning urine of a patient with diabetes mellitus. Indicators of albumin in biomaterial are in the range of more than 30-300 mg / day, or 20-200 ml in the first morning portion of urine.
Obvious symptoms of diabetic nephropathy appear in a patient with diabetes mellitus 15-20 years after the onset of complications. These include:
- Persistent proteinuria, in which a protein content of more than 300 mg / day is observed in the urine;
- The blood flow in the kidneys is weakened;
- Glomerular filtration rate decreases intensively;
- High blood pressure is constantly observed in the patient, and it is difficult to correct;
- The patient has regular tissue edema.
However, at this stage, the level of creatinine and urea in the blood is within normal limits or occasionally slightly increases.
At the final stages of the disease, a diabetic has the following symptoms:
- Regular high content of protein in urine, more often albumin;
- Extremely low glomerular filtration rate, range 15-30 ml / minute and less;
- Constant high levels of urea and creatinine in the blood;
- The frequent appearance of pronounced edema;
- Development of anemia;
- The level of glucose in the urine is significantly reduced;
- The blood sugar level of a diabetic approaches that of a healthy person;
- A large amount of endogenous insulin is excreted in the urine;
- The patient's need for exogenous insulin is significantly reduced;
- Blood pressure is regularly high;
- Difficulty, often painful, digestion occurs.
Simultaneously with this, self-poisoning of the body by the products of protein metabolism begins, which are lingering in it due to the pathology of the kidneys.
Stages of development of pathology and clinical manifestations
Diabetic nephropathy has several stages of development. Moreover, according to the generally accepted classification of Morgensen, the initial stage of diabetic nephropathy is considered to be the moment of onset of diabetes mellitus.
The stages of development of the disease are:
- Stage of renal dysfunction. The first stage of nephropathy lasts about 2-5 years from the onset of diabetes. This phase is accompanied by renal hypertrophy and hyperfiltration.
- The stage of developing structural changes in renal tissues. The stage begins 2-5 years later from the onset of diabetes mellitus. In the process of regression of the disease, a thickening of the basement membrane of the capillaries occurs.
- The stage of microalbuminuria or the onset of nephropathy. The period of regression of the disease to this stage is up to 10 years from the onset of diabetes mellitus. Microalbuminuria and an increase in glomerular filtration rate are observed.
- The phase of severe nephropathy, or macroalbuminuria. Roughly the patient enters this period 10-20 years after the onset of diabetes. The stage is accompanied by artegral hypertension in the patient, proteinuria, as well as sclerosis of up to 75% of the glomeruli and intensive excretion of proteins from the body.
- Stage uremic, or terminal. This phase of the disease begins approximately 15-20 years after the onset of diabetes, or 5-7 years after the onset of proteinuria. At this stage, there is a violation of nitrogen excretory function, sclerosis of up to 100% of the glomeruli, as well as a sharp decrease in the glomerular filtration rate.
The first 3 stages of diabetic nephropathy, if properly treated, are amenable to complete or partial regression. With timely detection and correct therapy, it is possible to slow down, and sometimes completely stop the further development of the 4th phase of the disease, pronounced nephropathy. The terminal stage of the disease is irreversible and requires the use of cardinal means for the patient's life support.
Diagnostic methods
Early diagnosis of a complication of diabetes mellitus, such as diabetic nephropathy, is extremely important for the start of timely and effective treatment of the disease. To identify pathology, the following analyzes are carried out:
- Blood chemistry;
- General blood analysis;
- Biochemical analysis of urine;
- General urine analysis;
- Rehberg's test, to determine the filtering ability of the kidneys. The test is carried out in conjunction with a biochemical and general analysis of blood and urine;
- Zimnitsky's test, to assess the ability of the kidneys to concentrate urine. For its implementation, the patient's urine is collected during the day in 8 different marked containers. In this case, both the amount of daily biomaterial and its density are analyzed;
- Doppler ultrasonography of the vessels of the kidneys, or USDG. Allows you to determine the condition of the blood vessels and the correctness of blood circulation in the tissues.
Biochemical blood test - one of the methods for diagnosing diabetic nephropathy In the initial stages of the development of complications, when there are no obvious symptoms of pathology, the main diagnostic method, to which primary attention is paid, is the Reberg test.
Every year in patients with diabetes mellitus, the ratio of albumin to creatinine in morning urine is determined. Also, the daily content of albumin in the urine is necessarily determined. Collecting data in dynamics makes it possible to trace even small deviations of indicators from the norm and to identify the onset of the development of pathology.
When examining the body for diabetic nephropathy, it is extremely important to carry out differential diagnosis of other renal diseases, which include:
- Chronic pyelonephritis;
- Tuberculosis;
- Chronic and acute glomerulonephritis.
To identify these pathologies, a bacteriological study (bacteriological culture) of urine for flora, ultrasound examination (ultrasound) of the kidneys and excretory urography are carried out. In rare cases, when there is suspicion of sudden development of nephropathy or persistent hematuria, a fine-needle aspiration biopsy of the kidney tissue is performed.
Treatment methods
Treatment of pathology, depending on the severity of the disease, can be carried out in the following ways:
- With the help of medicines;
- Dialysis;
- Surgically.
The main goal of therapy in the initial stages of the disease is to stop the development of diabetic neuropathy, and for this it is necessary to treat diabetes mellitus and all its complications.
Medication
The use of drugs is the mainstay of the treatment of diabetic nephropathy in the early stages. Also, medicines are actively used as an aid at the terminal stage.
In the course of treatment, drugs are used that ensure the correct functioning of the cardiovascular system, normalize blood sugar and blood pressure. The main drugs are from the group of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor antagonists (ARA).
From the ACE group, drugs are most often used:
- Enalapril;
- Ramipril;
- Trandolapril.
Enalapril - a drug for the treatment of diabetic nephropathy The main drugs from the ARA group are:
- Ibesartan;
- Valsartan;
- Losartan.
These drugs are used even with normal blood pressure, but at a reduced dosage to prevent the development of hypotension.
Starting from the stage of microalbuminuria, drugs are used to normalize the blood lipid spectrum, which include L-arginine, statins and folic acid. At the terminal stage, antiazothermal drugs and sorbents are necessarily used. The choice of medicines at any of the stages of the pathology is carried out only by the attending physician on an individual basis.
Dialysis
With an active decrease in the glomerular filtration rate, the indicators of which reach a level of 15 ml / minute and below, the patient requires renal replacement therapy. Dialysis is used to purify the blood. The procedure can be performed in two ways:
- Hemodialysis. Blood purification is carried out using a special apparatus with an artificial filtering membrane "Artificial kidney". To carry out the procedure in the forearm area, 2-3 months before the start of renal replacement therapy, a special tube, an arteriovenous fistula, is surgically inserted. This device connects a vein to an artery. The procedure is carried out in a special department of the hospital for 4 hours 3 days a week.
- Peritoneal dialysis. Purification of blood using the patient's peritoneum as a filtering membrane. Dialysis can be done at home. However, to apply the method, a special peritoneal catheter is inserted into the patient's abdominal cavity to inject dialysate solution. The process of blood purification is carried out daily 3-5 times.
In the case when the method of periodic artificial blood purification is ineffective, the patient may be prescribed surgical treatment.
Surgical
Surgically, the method of treating diabetic nephropathy involves the transplantation of a donor kidney. During the operation, you can use a related or cadaveric kidney. The main conditions for this are the good condition of the donor organ, as well as the correspondence of the blood groups and Rh factors of the donor and the patient.
Kidney transplant is one of the treatments for diabetic nephropathy Transplantation is performed in the iliac region. In order for the organ to take root in the new body, the patient is prescribed drugs that suppress the body's immune defenses. In some cases, patients with type 1 diabetes mellitus with end-stage diabetic nephropathy are prescribed simultaneous kidney and pancreas transplantation.
The Role of Diet in the Treatment of Diabetic Nephropathy
At any stage of diabetic nephropathy, it is important for patients to follow a special diet. At the same time, the list of acceptable and prohibited foods for dietary nutrition in the diet may vary, depending on the stage of the disease.
The diet of a patient with diabetic nephropathy at the beginning of the development of pathology, up to the stage of microalbuminuria, involves a partial restriction of the consumption of animal protein. In this case, the patient must adhere to the dietary rules for diabetics, ensuring a stable level of glucose in the blood.
So the amount of protein consumed in food should not exceed 12% of the daily calorie intake for a person. In a weight equivalent, the maximum amount of proteins can be 1 g per 1 kg of the patient's weight. If a diabetic with diabetic nephropathy has hypertension, foods with a high salt content are excluded from his menu. The ban is on pickled mushrooms, cucumbers, tomatoes and cabbage, the use of fish and mineral water is limited. The total amount of salt consumed per day, including that used in cooking, should not exceed 3 g.
At the stage of proteinuria, a low-protein diet is shown in which the maximum amount of protein consumed per day is calculated by the formula: 0.7 g per 1 kg of the patient's weight. Compliance with this diet is mandatory to prevent the transition of pathology to the terminal stage. The maximum amount of salt consumed by a diabetic per day should not exceed 2 g. The correct solution for a person suffering from diabetic nephropathy is to switch to a salt-free diet.
Prevention
Preventive measures for diabetic nephropathy consist in strict adherence to all medical prescriptions, as well as regular examination.
The prevention of the development of pathology is carried out by self-monitoring of the level of glucose in the blood, periodic diagnostics of the body and systematic examination by an endocrinologist-diabetologist.
Forecast
Reversible stages in the development of pathology are microalbuminuria and all the stages of pathology that precede it. With the timely detection of pathology, as well as correct treatment and strict adherence to all medical recommendations by the patient, the prognosis for the patient is favorable.
At the stage of proteinuria, it is only possible to maintain the patient's condition and prevent the development of chronic renal failure (CRF). The progression of the disease to the terminal stage is extremely dangerous and even incompatible with life. The survival rate of patients at this stage increases with the use of hemodialysis and kidney transplantation.
Diabetes affects the immune system negatively, so the patient gets sick more often. Antibiotics for diabetes are used in extreme cases when antimicrobial treatment is needed. The immune barrier is reduced, so the patient's body reacts to all pathogenic viruses. The appointment of such serious drugs is done exclusively by the doctor; in case of disturbed metabolic processes, the effect is opposite to what was expected or not achieved at all.
When are antibiotics used?
The body of a diabetic is vulnerable, so the infection can affect any part of the body. When a disease is diagnosed, immediate intervention is required. More often, antibiotics are prescribed in the presence of such pathologies:
- dermatological diseases;
- infections in the urinary system;
- diseases of the lower respiratory tract.
First of all, the effect occurs on organs with an increased load. The kidneys do not cope with their functions by 100%, therefore, infectious lesions can lead to nephropathy. Antibiotics and diabetes are concepts that are combined with caution. The appointment occurs in extreme cases when there is a risk of hypoglycemia. The acute course of the disease should take place under the supervision of a doctor in a hospital.
Respiratory tract pathologies
Antibiotic treatment is prescribed by the attending physician, taking into account the patient's state of health. Antibiotics for type 2 diabetes are prescribed according to the standard regimen. The cause is bronchitis or pneumonia. X-ray monitoring is carried out regularly, since the course of the disease is complicated by an initially weakened immune system. Protected penicillins are used in the treatment: "Azithromycin", "Grammidin" in combination with symptomatic therapy. Before use, carefully study the instructions, pay attention to the sugar content. With high blood pressure, antibiotics with a decongestant effect are prohibited. They combine the intake with probiotics and dietary supplements that preserve the microflora and prevent adverse reactions, especially in type 1 diabetics.
Skin infections
To eliminate symptoms, diabetics should pay attention to the sugar level, since a high value prevents healing and blocks the effect of antibiotics. The most common infectious diseases of the skin:
- furunculosis and carbuncle;
- necrotizing fasciitis.
Diabetic foot
When treating a diabetic foot, you need to prepare for a long and painful healing process. Bleeding ulcers form on the limbs, which are divided into 2 groups of severity. For diagnostics, samples are taken from the separated sequestration, an X-ray of the foot is performed. Antibiotics for diabetic feet are given by topical and oral administration. If there is an increased risk of limb amputation, for outpatient treatment are used: "Cephalexin", "Amoxicillin". Medications can be combined with a complex course of the disease. The course treatment is carried out for 2 weeks. The therapy is carried out in a comprehensive manner and consists of several stages:
- compensation for sugar sickness;
- reducing the load of the lower extremities;
- regular treatment of wounds;
- limb amputation with purulent-necrotic lesion, otherwise fatal.
Treatment of furunculosis and fasciitis
Furunculosis treatment regimen. Furunculosis and carbuncle recurrent diseases. The inflammatory process is localized on the scalp. It occurs when carbohydrate metabolism is disturbed and a therapeutic diet is not followed, accompanied by purulent-necrotic wounds in the deep layers of the skin. Antibacterial treatment: "Oxacillin", "Amoxicillin", the course of treatment is 1-2 months.
With necrotizing fasciitis, immediate hospitalization is required, since there is a high risk of spreading the infection throughout the body. The soft tissues of the shoulder, front thigh, and abdominal wall are affected. Treatment is carried out in a comprehensive manner, antibiotic therapy is only an addition to surgery.
Diabetes in the modern world has long acquired an ill-fame as a non-infectious epidemic.
The disease has become significantly younger in recent years, among patients of endocrinologists - both 30 and 20 years old.
If one of the complications, nephropathy, may appear after 5-10 years, then when it is often stated already at the time of diagnosis.
The diagnosis of diabetic nephropathy indicates damage to the filter elements (glomeruli, tubules, arteries, arterioles) in the kidneys as a result of a malfunction in the metabolism of carbohydrates and lipids.
The main reason for the development of nephropathy in diabetics is an increase in blood glucose levels.
At an early stage, the patient develops dryness, unpleasant taste in the mouth, general weakness and decreased appetite.
Also among the symptoms - an increase in the amount of urine excreted, frequent nighttime urge to urinate.
Nephropathy is also evidenced by changes in clinical analyzes: a decrease in hemoglobin level, specific gravity of urine, an increased level of creatinine, etc. disturbances in the work of the gastrointestinal tract, itching, edema and hypertension.
Important!
If a patient is diagnosed with diabetes, it is necessary to take a blood test for creatinine (with the calculation of the glomerular filtration rate) and a general urine test at least once a year to monitor the condition of the kidneys!
Differential diagnosis
In order to correctly establish the diagnosis, the doctor must make sure that the kidneys malfunctioned precisely due to diabetes, and not other diseases.
The patient should take a blood test for creatinine, urine for albumin, microalbumin and creatinine.
The basic indicators for the diagnosis of diabetic nephropathy are albuminuria and glomerular filtration rate (hereinafter GFR).
Moreover, it is the increase in the excretion of albumin (protein) in the urine that indicates the initial stage of the disease.
GFR in the early stages can also show elevated values that decrease as the disease progresses.
GFR is calculated using formulas, sometimes through the Reberg-Tareev test.
Normally, GFR is equal to or greater than 90 ml / min / 1.73 m2. The diagnosis of renal nephropathy is made to a patient if he has a decreased level of GFR for 3 months or more and there are abnormalities in the general clinical analysis of urine.
There are 5 main stages of the disease:
Treatment
The main goals in the fight against nephropathy are inextricably linked to diabetes management in general. These include:
- lowering blood sugar levels;
- stabilization of blood pressure;
- normalization of cholesterol levels.
Medication to combat nephropathy
For the treatment of high blood pressure during diabetic nephropathy well-proven ACE inhibitors.
They generally have a good effect on the cardiovascular system and reduce the risk of late stage nephropathy.
Sometimes patients have a reaction to this group of drugs in the form of a dry cough., then preference should be given to angiotensin-II receptor blockers. They are a little more expensive, but they have no contraindications.
It is impossible to use ACE inhibitors and angiotensin receptor blockers at the same time.
With a decrease in GFR, the patient needs to adjust the dose of insulin and antihyperglycemic drugs. This can only be done by a doctor based on the general clinical picture.
Hemodialysis: indications, effectiveness
Sometimes drug treatment does not give the desired results and the GFR falls below 15 ml / min / m2, then the patient is prescribed renal replacement therapy.
Also, her testimony includes:
- a clear increase in the level of potassium in the blood, which is not reduced by medication;
- fluid retention in the body, which can cause serious consequences;
- visible symptoms of protein-energy malnutrition.
One of the existing methods of replacement therapy, along with peritoneal dialysis and kidney transplantation, is hemodialysis.
To help the patient, he is connected to a special apparatus that performs the function of an artificial kidney - it cleanses the blood and the body as a whole.
This method of treatment is available in inpatient departments, since the patient must be near the apparatus for about 4 hours, 3 times a week.
Hemodialysis allows you to filter the blood, remove toxins and poisons from the body, and normalize blood pressure.
Possible complications include lowering blood pressure, infection.
Contraindications for hemodialysis are: severe mental disorders, tuberculosis, cancer, heart failure, stroke, some blood diseases, over 80 years of age. But in very severe cases, when a person's life is held by a thread, there are no contraindications for hemodialysis.
Hemodialysis allows you to temporarily restore kidney function, in general, it prolongs life by 10-12 years. Most often, doctors use this treatment as a temporary treatment before kidney transplantation.
Diet and prevention
The patient with nephropathy is obliged to use all possible levers for treatment. A properly selected diet will not only help with this, but will also improve the general condition of the body.
To do this, the patient should:
- consume protein foods as little as possible (especially of animal origin);
- limit the use of salt during cooking;
- with a low level of potassium in the blood, add foods rich in this element to the diet (bananas, buckwheat, cottage cheese, spinach, etc.);
- give up spicy, smoked, pickled, canned food;
- use high-quality drinking water;
- switch to fractional meals;
- limit the diet of foods high in cholesterol;
- give preference to the "right" carbohydrates.
Low protein diet- basic for patients with nephropathy. It has been scientifically proven that a large amount of protein food in the diet has a direct nephrotoxic effect.
At different stages of the disease, the diet has its own characteristics. For microalbuminaria, the protein in the total diet should be 12-15%, that is no more than 1 g per 1 kg of body weight.
If the patient suffers from high blood pressure, you need to limit the daily salt intake to 3-5 g (this is about one teaspoon). Food cannot be added to salt, daily calorie content is not more than 2500 calories.
At the stage of proteinuria protein intake should be reduced to 0.7 g per kilogram of weight, and salt - up to 2-3 g per day. From the diet, the patient should exclude all foods with a high salt content, give preference to rice, oatmeal and semolina, cabbage, carrots, potatoes, and some types of fish. Bread can only be salt-free.
Diet at the stage of chronic renal failure suggests reducing protein intake to 0.3 g per day and restriction in the diet of foods with phosphorus. If the patient feels "protein starvation", he is prescribed drugs with essential essential amino acids.
In order for a low-protein diet to be effective (that is, it inhibits the progression of sclerotic processes in the kidneys), the attending physician must achieve stable compensation for carbohydrate metabolism and stabilize blood pressure in the patient.
A low-protein diet has not only advantages, but also its limitations and disadvantages. The patient must systematically monitor the level of albumin, trace elements, the absolute number of lymphocytes and erythrocytes in the blood. And also keep a food diary and regularly adjust your diet, depending on the above indicators.
- specific pathological changes in the renal vessels that occur in diabetes mellitus of both types and lead to glomerulosclerosis, a decrease in the filtration function of the kidneys and the development of chronic renal failure (CRF). Diabetic nephropathy is clinically manifested by microalbuminuria and proteinuria, arterial hypertension, nephrotic syndrome, signs of uremia and chronic renal failure. The diagnosis of diabetic nephropathy is based on the determination of the level of albumin in the urine, the clearance of endogenous creatinine, the protein and lipid spectrum of the blood, the data of ultrasound of the kidneys, ultrasound of the renal vessels. In the treatment of diabetic nephropathy, diet, correction of carbohydrate, protein, fat metabolism, intake of ACE and ARA inhibitors, detoxification therapy, if necessary, hemodialysis, kidney transplantation are indicated.
General information
Diabetic nephropathy is a late complication of type 1 and type 2 diabetes mellitus and one of the main causes of death in patients with this disease. The damage to large and small blood vessels that develops in diabetes (diabetic macroangiopathies and microangiopathies) contributes to the defeat of all organs and systems, primarily the kidneys, eyes, and the nervous system.
Diabetic nephropathy is observed in 10-20% of patients with diabetes mellitus; somewhat more often, nephropathy complicates the course of the insulin-dependent type of disease. Diabetic nephropathy is diagnosed more often in male patients and in persons with type 1 diabetes mellitus that developed during puberty. The peak of development of diabetic nephropathy (stage of chronic renal failure) is observed when diabetes lasts 15-20 years.
Causes of Diabetic Nephropathy
Diabetic nephropathy is caused by pathological changes in the renal vessels and glomeruli of capillary loops (glomeruli) that perform a filtration function. Despite the various theories of the pathogenesis of diabetic nephropathy considered in endocrinology, hyperglycemia is the main factor and trigger of its development. Diabetic nephropathy occurs as a result of prolonged inadequate compensation for carbohydrate metabolism disorders.
According to the metabolic theory of diabetic nephropathy, persistent hyperglycemia gradually leads to changes in biochemical processes: non-enzymatic glycosylation of protein molecules of the renal glomeruli and a decrease in their functional activity; violation of water-electrolyte homeostasis, fatty acid metabolism, decreased oxygen transport; activation of the polyol pathway of glucose utilization and the toxic effect on the kidney tissue, increasing the permeability of the renal vessels.
The hemodynamic theory in the development of diabetic nephropathy assigns the main role to arterial hypertension and disorders of intrarenal blood flow: an imbalance in the tone of the inflow and outflow arterioles and an increase in blood pressure inside the glomeruli. Prolonged hypertension leads to structural changes in the glomeruli: first, to hyperfiltration with accelerated formation of primary urine and the release of proteins, then to the replacement of the renal glomerulus tissue with a connective tissue (glomerulosclerosis) with complete occlusion of the glomeruli, a decrease in their filtration capacity and the development of chronic renal failure.
The genetic theory is based on the presence of genetically determined predisposing factors in a patient with diabetic nephropathy, manifested in metabolic and hemodynamic disorders. In the pathogenesis of diabetic nephropathy, all three developmental mechanisms are involved and closely interact with each other.
Risk factors for diabetic nephropathy are arterial hypertension, prolonged uncontrolled hyperglycemia, urinary tract infections, fat metabolism disorders and overweight, male sex, smoking, and the use of nephrotoxic drugs.
Symptoms of Diabetic Nephropathy
Diabetic nephropathy is a slowly progressive disease, its clinical picture depends on the stage of pathological changes. In the development of diabetic nephropathy, the stages of microalbuminuria, proteinuria and the end stage of chronic renal failure are distinguished.
For a long time, diabetic nephropathy is asymptomatic, without any external manifestations. At the initial stage of diabetic nephropathy, there is an increase in the size of the glomeruli of the kidneys (hyperfunctional hypertrophy), increased renal blood flow, and an increase in the glomerular filtration rate (GFR). Several years after the onset of diabetes mellitus, initial structural changes in the glomerular apparatus of the kidneys are observed. The high volume of glomerular filtration remains, the excretion of albumin in the urine does not exceed normal values (<30 мг/сут).
Incipient diabetic nephropathy develops more than 5 years after the onset of the pathology and is manifested by constant microalbuminuria (> 30-300 mg / day or 20-200 mg / ml in the morning urine portion). There may be a periodic increase in blood pressure, especially with physical exertion. Deterioration of well-being of patients with diabetic nephropathy is observed only in the later stages of the disease.
Clinically pronounced diabetic nephropathy develops after 15-20 years in type 1 diabetes mellitus and is characterized by persistent proteinuria (urine protein level -> 300 mg / day), indicating the irreversibility of the lesion. Renal blood flow and GFR decrease, and arterial hypertension becomes permanent and difficult to correct. Nephrotic syndrome develops, manifested by hypoalbuminemia, hypercholesterolemia, peripheral and cavity edema. Levels of creatinine and blood urea are normal or slightly elevated.
At the terminal stage of diabetic nephropathy, there is a sharp decrease in the filtration and concentration functions of the kidneys: massive proteinuria, low GFR, a significant increase in the level of urea and creatinine in the blood, the development of anemia, pronounced edema. At this stage, hyperglycemia, glucosuria, urinary excretion of endogenous insulin, and the need for exogenous insulin can be significantly reduced. Nephrotic syndrome progresses, blood pressure reaches high values, dyspeptic syndrome, uremia and chronic renal failure develop with signs of self-poisoning of the body by metabolic products and damage to various organs and systems.
Diagnostics of the diabetic nephropathy
Early diagnosis of diabetic nephropathy is critical. In order to establish the diagnosis of diabetic nephropathy, a biochemical and general blood test, biochemical and general analysis of urine, Reberg's test, Zimnitsky's test, and ultrasound of kidney vessels are performed.
The main markers of early stages of diabetic nephropathy are microalbuminuria and glomerular filtration rate. At the annual screening of patients with diabetes mellitus, the daily urinary albumin excretion or the albumin / creatinine ratio in the morning portion is examined.
The transition of diabetic nephropathy to the stage of proteinuria is determined by the presence of protein in the general analysis of urine or the excretion of albumin in the urine above 300 mg / day. There is an increase in blood pressure, signs of nephrotic syndrome. The late stage of diabetic nephropathy is not difficult to diagnose: in addition to massive proteinuria and a decrease in GFR (less than 30-15 ml / min), an increase in the levels of creatinine and urea in the blood (azotemia), anemia, acidosis, hypocalcemia, hyperphosphatemia, hyperlipidemia, facial edema are added and the whole body.
It is important to carry out differential diagnosis of diabetic nephropathy with other kidney diseases: chronic pyelonephritis, tuberculosis, acute and chronic glomerulonephritis. For this purpose, bacteriological examination of urine for microflora, ultrasound of the kidneys, excretory urography can be performed. In some cases (with early and rapidly growing proteinuria, sudden development of nephrotic syndrome, persistent hematuria), a fine-needle aspiration kidney biopsy is performed to clarify the diagnosis.
Diabetic Nephropathy Treatment
The main goal of the treatment of diabetic nephropathy is to prevent and delay the further progression of the disease to chronic renal failure, to reduce the risk of developing cardiovascular complications (coronary artery disease, myocardial infarction, stroke). Common in the treatment of different stages of diabetic nephropathy is strict control of blood sugar, blood pressure, compensation for violations of mineral, carbohydrate, protein and lipid metabolism.
The drugs of first choice in the treatment of diabetic nephropathy are angiotensin-converting enzyme (ACE) inhibitors: enalapril, ramipril, trandolapril and angiotensin receptor antagonists (ARA): irbesartan, valsartan, losartan, which normalize systemic and intraglomerular diseases. The drugs are prescribed even at normal blood pressure in doses that do not lead to the development of hypotension.
Starting from the stage of microalbuminuria, a low-protein, salt-free diet is indicated: limiting the intake of animal protein, potassium, phosphorus and salt. To reduce the risk of developing cardiovascular diseases, dyslipidemia must be corrected through a low-fat diet and taking drugs that normalize the blood lipid spectrum (L-arginine, folic acid, statins).
At the terminal stage of diabetic nephropathy, detoxification therapy, correction of diabetes mellitus treatment, intake of sorbents, anti-azotemic agents, normalization of hemoglobin levels, prevention of osteodystrophy are required. In case of a sharp deterioration in renal function, the question is raised of whether the patient should be given hemodialysis, continuous peritoneal dialysis, or surgical treatment by donor kidney transplantation.
Forecast and prevention
Microalbuminuria with timely prescribed adequate treatment is the only reversible stage of diabetic nephropathy. At the stage of proteinuria, it is possible to prevent the progression of the disease to chronic renal failure, while reaching the terminal stage of diabetic nephropathy leads to a condition incompatible with life.
Currently, diabetic nephropathy and the resulting chronic renal failure are the leading indications for replacement therapy - hemodialysis or kidney transplantation. CRF due to diabetic nephropathy is responsible for 15% of all deaths among patients with type 1 diabetes mellitus younger than 50 years.
Prevention of diabetic nephropathy consists in the systematic observation of patients with diabetes mellitus by an endocrinologist-diabetologist, timely correction of therapy, constant self-monitoring of the level of glycemia, adherence to the recommendations of the attending physician.
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