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{{Diabetic nephropathy}}
{{Diabetic nephropathy}}
{{CMG}}
{{CMG}}; {{AE}}{{DN}}


==Overview==
==Overview==
The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is [[ACE inhibitor]] drugs, which usually reduces glomerular hypertension, [[proteinuria]] levels, [[systemic hypertension]] and slows the progression of diabetic nephropathy.
The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is [[ACE inhibitor]] drugs, which usually reduce glomerular hypertension, [[proteinuria]] levels, [[systemic hypertension]] and slow the progression of diabetic nephropathy.


==Medical Therapy==
==Medical Therapy==
* [[Anti-diabetic drug|Anti-diabetic drugs]] and injectable [[insulin analog]]s should be used to maintain normoglycemia.
See [[Diabetic nephropathy secondary prevention]]
* [[ACE inhibitors]] and [[ARB's]] are the drug of choice for controlling [[hypertension]] in diabetic nephropathy. Aggressive treatment of [[hypertension]] is found to retard the progression of damage to nephrons secondary to [[diabetes]]. Some advantages include:
 
===Lifestyle Modifications===
The management of diabetic nephropathy depends a lot on lifestyle and dietary modifications.These include:<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref>
*[[Weight loss]]
*Exercise
*[[Smoking cessation]]
*Reduction of salt and alcohol intake
*Limiting protein intake to less than 0.8 g per kg per day
 
===Blood Pressure Control===
[[Blood pressure]] in diabetic patients with [[nephropathy]] is aimed at levels of less than 130/80.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid11403001">{{cite journal |vauthors= |title=American Diabetes Association Clinical Practice Recommendations 2001 |journal=Diabetes Care |volume=24 Suppl 1 |issue= |pages=S1–133 |year=2001 |pmid=11403001 |doi= |url=}}</ref><ref name="pmid9834731">{{cite journal |vauthors=Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale JF, Zinman B, Lillie D |title=1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association |journal=CMAJ |volume=159 Suppl 8 |issue= |pages=S1–29 |year=1998 |pmid=9834731 |pmc=1255890 |doi= |url=}}</ref>
*[[ACE inhibitors]] and [[ARB's]] are the drug of choice for controlling [[hypertension]] in diabetic nephropathy.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref><ref name="pmid26928912">{{cite journal |vauthors=Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A |title=Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes |journal=Ann. Intern. Med. |volume=164 |issue=8 |pages=542–52 |year=2016 |pmid=26928912 |doi=10.7326/M15-3016 |url=}}</ref> Aggressive treatment of [[hypertension]] is found to retard the progression of damage to nephrons secondary to [[diabetes]]. Some advantages include:
** Lowering [[systemic hypertension]].
** Lowering [[systemic hypertension]].
** Lowering glomerular hypertension.
** Lowering glomerular hypertension.
** Dilatation of systemic and renal arterioles, increasing [[renal blood flow]].
** Dilatation of systemic and renal arterioles, increasing [[renal blood flow]].
** Rise in [[kinins]] which is also responsible for some of the side effects such as dry cough.[http://www.ksu.edu.sa/sites/Colleges/Medicine/Lists/Medical%20Subjects/Flat.aspx?RootFolder=http%3a%2f%2fwww%2eksu%2eedu%2esa%2fsites%2fColleges%2fMedicine%2fLists%2fMedical%20Subjects%2fDiabetes%20Mellitus%20and%20Angiotensin%20Converting%20Enzyme%20Inhibitors&FolderCTID=0x01200200CEDE56CEF8D11C46824F2F6116DF88AA]
** Rise in [[kinins]] which is also responsible for some of the side effects such as dry cough.[http://www.ksu.edu.sa/sites/Colleges/Medicine/Lists/Medical%20Subjects/Flat.aspx?RootFolder=http%3a%2f%2fwww%2eksu%2eedu%2esa%2fsites%2fColleges%2fMedicine%2fLists%2fMedical%20Subjects%2fDiabetes%20Mellitus%20and%20Angiotensin%20Converting%20Enzyme%20Inhibitors&FolderCTID=0x01200200CEDE56CEF8D11C46824F2F6116DF88AA]<br>
** [[ACE inhibitors]] and [[ARB's]] slow the progression of renal damage from [[diabetes]] to overt renal failure. It is recommended that all patients with [[type I diabetes mellitus|type I]] and [[type II diabetes mellitus]] with [[microalbuminuria]] on routine urine screening should be on [[ACE inhibitors]].
 
* [[Urinary tract]] and other [[infections]] are common and can be treated with appropriate [[antibiotics]].
* [[ACEI]] and [[ARBs]] should not be combined due to increased risk of [[hyperkalemia]] and [[acute kidney injury]] ([[AKI]]).<ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref><ref name="pmid26928912">{{cite journal |vauthors=Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A |title=Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes |journal=Ann. Intern. Med. |volume=164 |issue=8 |pages=542–52 |year=2016 |pmid=26928912 |doi=10.7326/M15-3016 |url=}}</ref>
* [[Dialysis]] may be necessary once end-stage renal disease develops. At this stage, a [[kidney transplantation]] must be considered. Another option for type 1 diabetes patients is a combined kidney-pancreas transplant, which is the preferred mode of renal replacement therapy in otherwise stable patients..
 
**[[Aldosterone antagonists]]: found to decrease blood pressure as well as [[proteinuria]], whether used alone or in combination with an [[ACEI]]/[[ARB]]. However, when used in combination with the other drugs, patients should be monitored for [[hyperkalemia]].<ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref>
**Other drugs, such as [[beta blockers]], [[calcium channel blockers]] and [[diuretics]] may be added if [[blood pressure]] is not well controlled.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid26928912">{{cite journal |vauthors=Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A |title=Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes |journal=Ann. Intern. Med. |volume=164 |issue=8 |pages=542–52 |year=2016 |pmid=26928912 |doi=10.7326/M15-3016 |url=}}</ref>


===Drug interaction===
===Lipid Therapy===
Patients with diabetic nephropathy should avoid taking the following drugs:
* The use of [[statins]] decreases the risk of [[cardiovascular disease]] and slows the loss of renal function.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid9742977">{{cite journal |vauthors= |title=Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group |journal=Lancet |volume=352 |issue=9131 |pages=854–65 |year=1998 |pmid=9742977 |doi= |url=}}</ref>
* Contrast agents containing [[iodine]]  
* For diabetic patients over the age of 40 with diabetic nephropathy, [[statins]] are recommended regardless of baseline [[lipid]] levels.<ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref><ref name="pmid11466120">{{cite journal |vauthors=Gerstein HC, Mann JF, Yi Q, Zinman B, Dinneen SF, Hoogwerf B, Hallé JP, Young J, Rashkow A, Joyce C, Nawaz S, Yusuf S |title=Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals |journal=JAMA |volume=286 |issue=4 |pages=421–6 |year=2001 |pmid=11466120 |doi= |url=}}</ref>
* Commonly used non-steroidal anti-inflammatory drugs ([[NSAID]]s) like [[ibuprofen]] and [[naproxen]], or [[COX-2]] inhibitors like [[Celebrex]], because they may injure the weakened kidney.
 
===Dialysis===
* [[Dialysis]] may be necessary once end-stage renal disease develops.


==References==
==References==
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{{Reflist|2}}
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[[Category:Pediatrics]]
 
[[Category:Endocrinology]]
[[Category:Nephrology]]


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Latest revision as of 13:04, 16 June 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Overview

The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is ACE inhibitor drugs, which usually reduce glomerular hypertension, proteinuria levels, systemic hypertension and slow the progression of diabetic nephropathy.

Medical Therapy

See Diabetic nephropathy secondary prevention

Lifestyle Modifications

The management of diabetic nephropathy depends a lot on lifestyle and dietary modifications.These include:[1]

Blood Pressure Control

Blood pressure in diabetic patients with nephropathy is aimed at levels of less than 130/80.[1][2][3]

Lipid Therapy

Dialysis

  • Dialysis may be necessary once end-stage renal disease develops.

References

  1. 1.0 1.1 1.2 1.3 1.4 Remuzzi G, Schieppati A, Ruggenenti P (2002). "Clinical practice. Nephropathy in patients with type 2 diabetes". N. Engl. J. Med. 346 (15): 1145–51. doi:10.1056/NEJMcp011773. PMID 11948275.
  2. "American Diabetes Association Clinical Practice Recommendations 2001". Diabetes Care. 24 Suppl 1: S1–133. 2001. PMID 11403001.
  3. Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale JF, Zinman B, Lillie D (1998). "1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association". CMAJ. 159 Suppl 8: S1–29. PMC 1255890. PMID 9834731.
  4. 4.0 4.1 4.2 4.3 Lim A (2014). "Diabetic nephropathy - complications and treatment". Int J Nephrol Renovasc Dis. 7: 361–81. doi:10.2147/IJNRD.S40172. PMC 4206379. PMID 25342915. Vancouver style error: initials (help)
  5. 5.0 5.1 5.2 Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A (2016). "Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes". Ann. Intern. Med. 164 (8): 542–52. doi:10.7326/M15-3016. PMID 26928912.
  6. "Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group". Lancet. 352 (9131): 854–65. 1998. PMID 9742977.
  7. Gerstein HC, Mann JF, Yi Q, Zinman B, Dinneen SF, Hoogwerf B, Hallé JP, Young J, Rashkow A, Joyce C, Nawaz S, Yusuf S (2001). "Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals". JAMA. 286 (4): 421–6. PMID 11466120.


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