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Diabetic nephropathy

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Updated 2024 KDIGO guidelines for the management of diabetic nephropathy.

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 2024), 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 2024 guidelines:
Assess urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR at least annually in all patients with T2DM, regardless of treatment.
B
Monitor urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR 1-4 times per year, depending on the stage of the disease, in patients with established diabetic kidney disease.
B
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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.
E
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  • Goals of treatment

  • Glycemic control

  • BP control

  • Metformin

  • GLP-1 receptor agonists

  • SGLT-2 inhibitors

  • Renin-angiotensin system inhibitors

  • Mineralocorticoid receptor antagonists

Nonpharmacologic interventions

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

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  • Protein intake

Specific circumstances

Pregnant patients: as per KDIGO 2022 guidelines, advise contraception in female patients receiving ACEIs or ARBs and discontinue these agents in patients considering pregnancy or becoming pregnant.
E

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  • Pediatric patients

Preventative measures

Primary prevention, glycemic control: as per ADA 2024 guidelines, optimize glucose management to reduce the risk of CKD.
A

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  • Primary prevention (BP control)

  • Primary prevention (RAAS blockers)

Follow-up and surveillance

Indications for specialist referral
As per ADA 2024 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.
A
Refer patients promptly to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease.
B

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  • Serial laboratory monitoring