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Diabetic nephropathy

What's new

Diabetes Canada has released a new guideline for the management of chronic kidney disease (CKD) in diabetes. Annual screening with eGFR and random urine ACR is recommended for all patients with diabetes, starting at diagnosis for type 2 and 5 years after onset or after puberty for type 1. CKD is defined by eGFR <60 mL/min/1.73 m² and/or ACR ≥2.0 mg/mmol on repeat testing. More frequent monitoring (every 3-6 months) is recommended if eGFR is <60 or ACR >20. Combined creatinine-cystatin C eGFR may be used when creatinine-based estimates are unreliable. The Kidney Failure Risk Equation is suggested for patients with CKD stages G3-G5. Treatment includes RAAS inhibitors for patients with hypertension or albuminuria. SGLT2 inhibitors are recommended for those with eGFR 20-45 or higher with elevated ACR, while GLP-1 receptor agonists and nonsteroidal MRAs (such as finerenone) may be added in patients with persistent proteinuria. .

Background

Overview

Definition
DN is a chronic microvascular complication of diabetes characterized by glomerular hyperfiltration, progressive albuminuria, and reduced GFR.
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Pathophysiology
DN is caused due to hyperfiltration and reduction of GFR mainly due to hyperglycemia, systemic hypertension, and obesity.
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Disease course
Clinical manifestations of DN include microalbuminuria, macroalbuminuria, hyperglycemia, refractory hypertension, diabetic retinopathy, nephrotic or nephritic syndrome, anemia, bone and mineral metabolism complications. Disease progression may lead to CVD, infections, ESRD, and death.
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Prognosis and risk of recurrence
1-year mortality of patients on dialysis is around 21.5% in the US.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of diabetic nephropathy are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025,2024), the Diabetes Canada (DC 2025), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2024,2022), the European Society of Cardiology (ESC 2023), and the Canadian Cardiovascular Society (CCS 2022).
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Diagnostic investigations

Laboratory testing
As per ADA 2025 guidelines:
Assess kidney function (spot urinary albumin-to-creatinine ratio and eGFR) in all patients with T2DM, regardless of treatment.
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Monitor urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR 1-4 times per year in patients with established diabetic kidney disease, depending on the stage of the disease.
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Medical management

General principles: as per KDIGO 2022 guidelines, treat patients with diabetes mellitus and CKD with a comprehensive strategy to reduce risks of kidney disease progression and CVD.
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  • Goals of treatment

  • Glycemic control

  • BP control

  • Metformin

  • GLP-1 receptor agonists

  • SGLT-2 inhibitors

  • RAAS inhibitors (ACEis/ARBs)

  • RAAS inhibitors (mineralocorticoid receptor antagonists)

  • Management of hyperkalemia

Nonpharmacologic interventions

Smoking cessation
As per KDIGO 2022 guidelines:
Advise patients with diabetes mellitus and CKD to quit using tobacco products.
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Counsel patients with diabetes mellitus and CKD to reduce secondhand smoke exposure.
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  • Protein intake

Specific circumstances

Pediatric patients: as per ADA 2024 guidelines, advise protein intake at the recommended daily allowance of 0.85 g/kg/day (according to age).
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  • Pregnant patients

Preventative measures

Primary prevention, glycemic control: as per ADA 2025 guidelines, optimize glucose management to reduce the risk of CKD.
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  • Primary prevention (BP control)

  • Primary prevention (RAAS blockers)

Follow-up and surveillance

Indications for specialist referral
As per ADA 2025 guidelines:
Refer patients with continuously increasing urinary albumin levels and/or continuously decreasing eGFR and/or eGFR < 30 mL/min/1.73 m² for evaluation by a nephrologist.
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Refer patients promptly to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease.
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  • Laboratory follow-up