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| __NOTOC__
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| {{Diabetic nephropathy}}
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| {{CMG}}; {{AE}}{{DN}}
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| ==Overview==
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| 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.
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| ==Medical Therapy==
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| Medical treatment in diabetic nephropathy is aimed at slowing the progression of [[albuminuria]]. Interventions include improved glycemic control, a strict control of [[blood pressure]], treatment of [[dyslipidemia]], as well as administration of an [[angtiontensin converting enzyme inhibitor]] ([[ACEI]]) or an [[angiotensin receptor blocker]] ([[ARBs]]).<ref name="book">{{cite book |last= Kasper |first=Dennis |date=2015 |title=Harrison's Principles of Internal Medicine |url= |location= New York, New York |publisher= McGraw-Hill |page= |isbn=0071802150}}</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>
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| ===Lifestyle Modifications===
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| 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>
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| *Weight loss
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| *Exercise
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| *Smoking cessation
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| *Reduction of salt and alcohol intake
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| *Limiting protein intake to less than 0.8 g per kg per day
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| ===Glycemic Control===
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| Glycemic control is effective in reducing the microvascular complications of [[diabetes mellitus]], as well as lowering the incidence of [[microalbuminuria]] and [[macroalbuminuria]]. In general, an [[HbA1c]] of less than 7.0% is considered adequate glycemic control. However, very tight glycemic control (i.e: [[HbA1c]] levels of less than 6.0% is associated with an increased mortality and [[cardiovascular disease]]. [[Anti-diabetic drug|Anti-diabetic drugs]] and injectable [[insulin analog]]s should be used to maintain normoglycemia. While a strict glycemic control reduces the rate at which [[microalbuminura]] appears and progress in patients with both type I and type II [[diabetes mellitus]], it is debatable as to whether or not an improved blood [[glucose]] control halts the progression of renal disease once [[microalbuminuria]] is present.<ref name="pmid8487827">{{cite journal |vauthors=Nathan DM |title=Long-term complications of diabetes mellitus |journal=N. Engl. J. Med. |volume=328 |issue=23 |pages=1676–85 |year=1993 |pmid=8487827 |doi=10.1056/NEJM199306103282306 |url=}}</ref><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><br>
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| Certain [[anti-diabetic drug|anti-diabetic drugs]] have additional benefits in addition to lowering blood [[glucose]] levels. These include:<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>
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| *PPAR-ɣ inhibitors, such as [[pioglitazone]] and [[rosiglitazone]] have anti-fibrotic and [[anti-inflammatory]] effects.
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| *[[DPP-4 inhibitors]], such as [[sitagliptin]] has [[anti-inflammatory]] and anti-apoptotic properties. When [[sitagliptin]] is used for 6 months in patients with type II [[DM]], it reduces the rate of albuminuria in these patients.<ref name="pmid24843780">{{cite journal |vauthors=Mori H, Okada Y, Arao T, Tanaka Y |title=Sitagliptin improves albuminuria in patients with type 2 diabetes mellitus |journal=J Diabetes Investig |volume=5 |issue=3 |pages=313–9 |year=2014 |pmid=24843780 |pmc=4020336 |doi=10.1111/jdi.12142 |url=}}</ref>
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| *SGLT-2 inhibitors decrease the rate of hyperfiltration by exerting an effect on [[tubuloglomerular feedback]].<ref name="pmid24334175">{{cite journal |vauthors=Cherney DZ, Perkins BA, Soleymanlou N, Maione M, Lai V, Lee A, Fagan NM, Woerle HJ, Johansen OE, Broedl UC, von Eynatten M |title=Renal hemodynamic effect of sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetes mellitus |journal=Circulation |volume=129 |issue=5 |pages=587–97 |year=2014 |pmid=24334175 |doi=10.1161/CIRCULATIONAHA.113.005081 |url=}}</ref><ref name= "NEJM">{{cite journal |last=Anders |first=Hans‐Joachim |last2=Davis |first2=John M. |last3=Thurau |first3=Klaus |date=2016 |title=Nephron Protection in Diabetic Kidney Disease |url= |journal=The New England Journal of Medicine |volume=375 |issue=21 |pages=2096-2098 |doi=10.1056/NEJMcibr1608564 |access-date= }}</ref>
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| Drugs such as [[metformin]] and [[sulfonylureas]] are contraindicated in advanced renal insufficiency.<ref name="book">{{cite book |last= Kasper |first=Dennis |date=2015 |title=Harrison's Principles of Internal Medicine |url= |location= New York, New York |publisher= McGraw-Hill |page= |isbn=0071802150}}</ref>
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| ===Blood Pressure Control===
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| [[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>
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| *[[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:
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| ** Lowering [[systemic hypertension]].
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| ** Lowering glomerular hypertension.
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| ** Dilatation of systemic and renal arterioles, increasing [[renal blood flow]].
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| ** 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>
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| [[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>
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| *[[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>
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| *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>
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| ===Lipid Therapy===
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| 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> 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>
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| ===Dialysis===
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| [[Dialysis]] may be necessary once end-stage renal disease develops.
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| ==References==
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| {{Reflist|2}}
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