Glomerular Diseases in Diabetic Patients: Implications for Diagnosis and Management

Abstract

The prevalence of diabetes continues to rise worldwide. In addition to rising rates of diabetic kidney disease, we are also seeing a parallel rise in nondiabetic kidney disease among patients with diabetes. These nondiabetic lesions include focal segmental glomerulosclerosis, IgA nephropathy, membranous nephropathy, and other glomerular diseases. The management of diabetic kidney disease is rapidly evolving to include, beyond glycemic control and renin angiotensin inhibition, the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and mineralocorticoid receptor antagonists. These and other new treatment strategies should be applicable to managing glomerular disease in diabetic patients to reduce toxicities associated with immunosuppression and, in particular, corticosteroids. The prevalence of glomerular disease in diabetic patients is underappreciated. Diagnosis and appropriately treating these diseases remain an important avenue to modify kidney outcomes in diabetic patients.

Keywords: IgA nephropathy; diabetes mellitus; focal segmental glomerulosclerosis; glomerulonephritis; nondiabetic kidney disease; nondiabetic renal disease; obesity-related glomerulopathy.

Figure 1

Kidney biopsy findings in a diabetic patient study from the Columbia Renal Pathology Laboratory, in 2011 [6]. Global frequencies including nondiabetic kidney disease (NDKD) alone and NDKD associated with diabetic nephropathy (DN). Focal segmental glomerulosclerosis (FSGS), hypertensive nephrosclerosis (HTN), acute tubular necrosis (ATN), IgA nephropathy (IgAN), membranous nephropathy (MN), and others.

Figure 2

Indications for kidney biopsy in patients with diabetes and suspected nondiabetic kidney disease. One or more of the following criteria should raise suspicion of NDKD and prompt a kidney biopsy in diabetic patients.