🌟JOIN Master the art of medical diagnosis only At 99 Rs https://bit.ly/Mediagnosis *CASE STUDY: DIABETIC NEPHROPATHY* ©️🅾️🅰️ INTRODUCTION Definition: Diabetic nephropathy is a progressive kidney disease caused by long-standing diabetes mellitus, characterized by persistent albuminuria, declining glomerular filtration rate (GFR), and increased blood pressure. It is the leading cause of end-stage renal disease (ESRD) worldwide. Distribution: Global incidence: Affects approximately 20–40% of patients with diabetes. Africa: Prevalence among diabetic patients ranges from 10–30%, with higher rates in urban populations and among those with poor glycemic control. Nigeria: Diabetic nephropathy accounts for 12–20% of chronic kidney disease cases. Mortality: Global: Diabetic nephropathy significantly increases cardiovascular and all-cause mortality among diabetic patients. Sub-Saharan Africa: Limited data, but mortality is high due to late presentation and limited access to renal replacement therapy. ETIOLOGY AND PATHOGENESIS Primary Causative Factors: Chronic hyperglycemia leading to glomerular hyperfiltration and injury Hypertension exacerbating glomerular damage Genetic predisposition Dyslipidemia and smoking as contributing risk factors Pathogenesis: Hyperglycemia induces advanced glycation end-products (AGEs) and oxidative stress, resulting in mesangial expansion, glomerular basement membrane thickening, and podocyte loss. Progressive proteinuria leads to tubulointerstitial fibrosis and declining renal function. RISK FACTORS Poor glycemic control (HbA1c >7%) Long duration of diabetes (>10 years) Hypertension (BP >140/90 mmHg) Family history of diabetic nephropathy Obesity Dyslipidemia Smoking African ancestry (higher susceptibility) Male gender Coexisting microvascular complications (retinopathy, neuropathy) PATIENT PROFILE Name: M. A. Age: 58 years Gender: Male Location: Lagos, Nigeria Occupation: Civil servant Medical History: Type 2 diabetes (15 years), hypertension, dyslipidemia, background diabetic retinopathy CHIEF COMPLAINTS Swelling of legs and face for 2 weeks Frothy urine Fatigue and reduced exercise tolerance Poor glycemic control PHYSICAL EXAMINATION Vital Signs: Blood Pressure: 158/96 mmHg Heart Rate: 88 bpm Respiratory Rate: 18 breaths/min Temperature: 36.8°C Oxygen Saturation: 98% on room air General Appearance: Periorbital and pedal edema, overweight Cardiovascular: No murmurs, normal heart sounds Respiratory: Clear breath sounds Abdomen: No organomegaly, mild ascites Neurological: Intact, no focal deficits DIAGNOSTIC INVESTIGATIONS Laboratory Tests: Urinalysis: Proteinuria (+++), no hematuria Urine albumin-to-creatinine ratio (ACR): 450 mg/g (macroalbuminuria) Serum creatinine: 2.1 mg/dL (elevated) Estimated GFR: 38 mL/min/1.73m² (stage 3b CKD) Fasting blood glucose: 180 mg/dL HbA1c: 8.9% (elevated) Lipid profile: LDL 145 mg/dL, HDL 32 mg/dL, triglycerides 210 mg/dL Serum albumin: 2.8 g/dL (low) Electrolytes: Mild hyperkalemia (K+ 5.6 mmol/L) Imaging: Renal ultrasound: Normal-sized kidneys, increased echogenicity, no obstruction Additional Tests: Fundoscopy: Background diabetic retinopathy ECG: Left ventricular hypertrophy MANAGEMENT Immediate Interventions: Blood pressure control: Start ACE inhibitor (e.g., Lisinopril 10 mg daily) Glycemic control: Intensify insulin therapy, dietician review Statin therapy for dyslipidemia Salt and protein restriction in diet Diuretics (e.g., furosemide) for edema Patient education on lifestyle modification Supportive Care: Monitor fluid status and electrolytes Treat underlying infections if present Vaccination: Influenza and pneumococcal vaccines CARE PLAN (3–6 months) Day 1–7: Initiate ACE inhibitor, statin, and optimize diabetes regimen Monitor BP, renal function, and electrolytes Begin dietary counseling and fluid/salt restriction Daily weight and edema assessment Week 2–4: Titrate antihypertensive and diuretic doses as needed Monitor for side effects (e.g., cough, hyperkalemia) Reinforce glycemic and dietary targets Assess for improvement in edema Month 2–3: Repeat renal function, ACR, and lipid profile Assess for reduction in proteinuria and stabilization of renal function Continue patient education and support Month 4–6: Evaluate for complications (anemia, bone disease) Plan for nephrology referral if rapid progression or advanced CKD Review adherence and address barriers to care HEALTH EDUCATION Importance of strict blood sugar and blood pressure control Adherence to medication and dietary recommendations Early recognition of symptoms (edema, reduced urine output) Smoking cessation and weight management Regular follow-up and laboratory monitoring OUTCOME AND FOLLOW-UP Monthly clinic visits for BP, glycemic, and renal function monitoring Repeat ACR and eGFR every 3–6 months Annual fundoscopy and foot examination Early nephrology referral if eGFR <30 mL/min/1.73m² or rapid decline Ongoing patient support and education PREVENTION STRATEGIES Early screening for microalbuminuria in all diabetic patients Intensive glycemic and blood pressure control Use of renin-angiotensin system blockers (ACE inhibitors/ARBs) Lipid management with statins Lifestyle modification: diet, exercise, smoking cessation Patient education and regular follow-up References: American Diabetes Association. Standards of Medical Care in Diabetes—2025. Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Ulasi II, Ijoma CK. The Burden of Chronic Kidney Disease in Nigeria and Strategies for Prevention. Kidney Int Suppl. 2010;3(2):195-201. World Health Organization. Global Report on Diabetes. 2024. ©️🅾️🅰️