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Diabetic nephropathy

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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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 European Society of Cardiology (ESC 2023), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2022), and the Canadian Cardiovascular Society (CCS 2022).
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Guidelines

1.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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2.Medical management

General principles: treat patients with diabetes mellitus and CKD with a comprehensive strategy to reduce risks of kidney disease progression and CVD.
B
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  • Goals of treatment

  • Glycemic control

  • BP control

  • Metformin

  • GLP-1 receptor agonists

  • SGLT-2 inhibitors

  • RAAS blockers

3.Nonpharmacologic interventions

Dietary protein intake: aim to a target level of 0.8 g/kg body weight/day of dietary protein intake in patients with nondialysis-dependent stage ≥ G3 CKD.
A
consider targeting 1.0-1.2 g/kg/day of dietary protein intake in patients on dialysis since protein energy wasting is a major problem in some patients on dialysis.
B

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  • Smoking cessation

4.Specific circumstances

Pediatric patients: advise protein intake at the recommended daily allowance of 0.85 g/kg/day (according to age).
B
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5.Preventative measures

Primary prevention, glycemic control: optimize glucose management to reduce the risk of CKD.
A

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  • Primary prevention (BP control)

  • Primary prevention (RAAS blockers)

6.Follow-up and surveillance

Indications for specialist referral
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.
B

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  • Serial laboratory monitoring