Rapidly progressive diabetic kidney disease: South Asian experience

Objective: There is limited discussion in the literature on clinical and pathological features of the rapidly progressive variant of diabetic nephropathy (DN). We aim to highlight the clinic-pathologic characteristics of biopsy proven DN in patients with type 2 diabetes (T2DM) and a rapid decline in glomerular filtration rate (GFR). Methods: We conducted a cross sectional study of patients with rapidly declining GFR and biopsy proven isolated DN from 2012 to 2018. Data on clinical details, laboratory, and histologic findings was collected. Results: A total of 46 patients were included; mean age was 49 ± 12.7 years with a predominantly male preponderance. Majority of the patients (82%) had hypertension and more than 40% required more than one antihypertensive medications. About half of the patients (47%) were on renin-angiotensin-system (RAS) inhibitors, and 70% were either overweight or obese. Almost half of the patients had HbA1c values greater than 7% and about 71% were on insulin. Mean urinary protein was 4.5 ± 2.6 g. Nodular and global glomerulosclerosis were the most common histologic findings, while 26.1% patients had crescents. During follow-up, 30% had one or more hospitalizations with congestive heart failure and 30% progressed to end-stage kidney disease (ESKD). Mean time to ESKD was 9.69 ± 17.87 months. Conclusion: Younger age, higher body mass index, coexisting hypertension, overt proteinuria, and suboptimal glycemic and blood pressure control with underutilization of RAS inhibitors were prevalent in rapid decliners in DKD. Rapidly progressive diabetic kidney disease is a globally under-recognized entity, and this is the first experience shared from the South Asian region.