5.1 Diabetic nephropathy

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It is a specific form of microangiopathy of the kidney which is characterized by:

  • Persistent albuminuria
  • Progressive renal insufficiency (declining eGFR) with or without hypertension2

 

5.1.1 Albuminuria

  • Albumin-to-creatinine ratio (ACR) is the preferred method to detect elevated protein in urine. The recommended method to evaluate albuminuria is to measure urinary ACR in a spot urine sample (preferably morning fasting sample before exercise).
  • ACR is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams.
  • Normal: ACR <30 mg/g, normal to mildly increased albuminuria.
  • Microalbuminuria: ACR 30-<300 mg/g, moderately increased albuminuria.
  • Macroalbuminuria: ACR >300 mg/g, severely increased albuminuria.2

Table 5.1 Stages of CKD by eGFR3

Table 5.1 Stages of CKD by eGFR3

Markers of renal damage (one or more)4

  • Albuminuria (AER ≥30 mg/24 hours; ACR ≥30 mg/g [≥3 mg/mmol])
  • Urine sediment abnormalities
  • Electrolyte and other abnormalities due to tubular disorders
  • Abnormalities detected by histology
  • Structural abnormalities detected by imaging
  • History of kidney transplantation

5.1.2 Screening and follow up

5.1.2 Screening and follow up2

  • Full clinical check-up during each visit, especially anemia, blood pressure, pedal edema etc.
  • AER (albumin excretion rate) and eGFR or CCr estimation. Two of three samples of AER should be abnormal in 3-6 months.
  • Blood urea, creatinine, total protein, albumin, electrolytes, uric acid, calcium and phosphate estimation.
  • Serum creatinine and eGFR should be assessed at least annually.
  • Monitoring of other urinary complications e.g. UTI (including asymptomatic), bladder dysfunction (autonomic bladder) etc.
  • Monitoring by sonography – kidney size, progressive increase in echogenicity of cortex.
  • Renal biopsy may be required in nephropathy in absence of retinopathy, heavy proteinuria, rapid unexplained deterioration of renal function etc.

5.1.3 Treatment

5.1.3 Treatment2

  • Good glycemic control reduces the incidence of diabetic nephropathy and delays its progression, evidence suggests that SGLT2 inhibitors and GLP1-RA are beneficial, if not contraindicated.
  • Control of hypertension is very important because uncontrolled hypertension causes rapid progression of diabetic nephropathy. Target of BP is <130/80 mm of Hg.
  • ACE inhibitors and ARBs are preferred drugs to reduce or revert early nephropathy. But these two drugs must not be combined. Check electrolytes and creatinine 2 weeks after starting and stop if >30% increase of baseline serum creatinine or hyperkalemia.
  • Protein intake up to 0.8 gm/kg/day of body weight is allowed.
  • Correct high phosphate and uric acid. Restrict high uric acid and phosphate-containing foods if necessary.
  • Fluid and electrolyte balance should be maintained.
  • Iron supplementation often fails to correct anemia in renal failure. Iron along with erythropoietin provides the optimum response.
  • Renal replacement therapy (dialysis and renal transplantation) is done when indicated.

Figure 5.1 Decision making path: nephropathy2

Figure 5.1 Decision making path: nephropathy2