Renal structure in type 2 diabetes: facts and misconceptions
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REVIEW
Renal structure in type 2 diabetes: facts and misconceptions Angelo Di Vincenzo1 · Silvia Bettini1 · Lucia Russo1 · Sara Mazzocut1 · Michael Mauer2 · Paola Fioretto1 Received: 22 June 2020 / Accepted: 2 July 2020 © The Author(s) 2020
Abstract The clinical manifestations of diabetic nephropathy are similar in type 1 and type 2 diabetes, while the renal lesions may differ. Indeed, diabetic glomerulopathy is the predominant renal lesion in type 1 diabetes, although also tubular, interstitial and arteriolar lesions are present in the advanced stages of renal disease. In contrast, in type 2 diabetes renal lesions are heterogeneous, and a substantial number of type 2 diabetic patients with diabetic kidney disease have mild or absent glomerulopathy with tubulointerstitial and/or arteriolar abnormalities. In addition, a high prevalence of non-diabetic renal diseases, isolated or superimposed on classic diabetic nephropathy lesions have been reported in patients with type 2 diabetes, often reflecting the bias of selecting patients for unusual clinical presentations for renal biopsy. This review focuses on renal structural changes in type 2 diabetes, emphasizing the contribution of research kidney biopsy studies to the understanding of the pathogenesis of DKD and of the structural lesions responsible for the different clinical phenotypes. Also, kidney biopsies could provide relevant information in terms of renal prognosis, and help to understand the different responses to different therapies, especially SGLT2 inhibitors, thus allowing personalized medicine. Keywords Diabetic nephropathy · Kidney biopsy · Mesangial expansion · Tubulointerstitial lesions · Morphometric analysis
Introduction Renal disease (hereafter referred to as diabetic kidney disease or DKD) affects approximately 40% of patients with diabetes, and is the most common cause of end-stage renal disease (ESRD) worldwide, accounting for almost half of patients on renal replacement treatment in the USA [1]. In the 2016 European Renal Association (ERA)—European Dialysis and Transplant Association (EDTA) registry annual report, 25% of patients starting renal replacement therapy (RRT) were affected by diabetes [2]. The development of DKD in both type 1 and type 2 diabetes is the main predictor of mortality, and is associated with a worst prognosis in diabetic compared to non-diabetic subjects [3]. DKD is strongly associated with increased cardiovascular risk; indeed a large majority of patients with DKD die of * Paola Fioretto [email protected] 1
Department of Medicine, Clinica Medica 3, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
Department of Pediatrics and Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
2
cardiovascular complications before reaching ESRD [4]. The clinical manifestations of DKD are common to those of other chronic kidney diseases, i.e., proteinuria, declining GFR and hypertension, while the lesions underlying renal dysfunction are typical of this disease. This is especially tru
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