What is the treatment for nephropathy (kidney disease)?

From the Guidelines

The treatment of nephropathy should prioritize blood pressure control with ACE inhibitors or ARBs, as well as lifestyle modifications, to reduce proteinuria and slow disease progression, as recommended by the most recent and highest quality study 1.

Key Components of Nephropathy Treatment

• Blood pressure control with ACE inhibitors (like enalapril 10-40 mg daily or lisinopril 10-40 mg daily) or ARBs (such as losartan 50-100 mg daily) to reduce proteinuria and slow disease progression 1
• Glycemic control for diabetic nephropathy, targeting HbA1c below 7% using medications like metformin, SGLT2 inhibitors, or GLP-1 receptor agonists
• Dietary modifications, including:
  • Sodium restriction (<2g/day)
  • Protein moderation (0.8g/kg/day)
  • Potassium restriction in advanced disease
• Lifestyle modifications, including:
  • Weight management
  • Smoking cessation
  • Regular exercise

Monitoring and Referral

• Regular monitoring of kidney function, proteinuria, and electrolytes is crucial
• Referral to a specialist (nephrologist) for consultation and comanagement if the patient's personal physician cannot adequately evaluate and treat the patient, particularly when GFR falls below 30 mL/min per 1.73 m2 1

Advanced Nephropathy

• Preparation for renal replacement therapy (dialysis or transplantation) may be necessary when GFR falls below 15-20 ml/min
• These interventions work by reducing intraglomerular pressure, decreasing inflammation, and minimizing further kidney damage 1

From the FDA Drug Label

1. 3 Nephropathy in Type 2 Diabetic Patients Losartan is indicated for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and a history of hypertension In this population, losartan reduces the rate of progression of nephropathy as measured by the occurrence of doubling of serum creatinine or end stage renal disease (need for dialysis or renal transplantation) [see CLINICAL STUDIES (14.3)].

Treatment of Nephropathy: Losartan is indicated for the treatment of diabetic nephropathy in patients with type 2 diabetes and a history of hypertension.

• Key Benefits: Reduces the rate of progression of nephropathy, as measured by the occurrence of doubling of serum creatinine or end-stage renal disease.
• Target Population: Patients with type 2 diabetes, elevated serum creatinine, and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g). 2

From the Research

Treatment of Nephropathy

• The treatment of nephropathy, particularly hypertensive nephropathy, involves the use of renin-angiotensin-aldosterone (RAAS) blockers to reduce albuminuria and control blood pressure 3.
• Aggressive blood pressure lowering with multiple agents, including RAAS blockers, calcium antagonists, and diuretics, is recommended to slow the progression of hypertensive nephropathy to end-stage renal disease (ESRD) 3.
• Angiotensin II receptor blockers (ARBs) have been shown to be effective in preventing the development of clinical proteinuria and delaying the progression of nephropathy in type 2 diabetic patients 4.
• The use of ARBs has also been associated with a reduction in hospitalizations for heart failure and a decrease in cardiovascular morbidity and mortality in diabetic patients with hypertension and left ventricular hypertrophy 4.

Treatment Strategies

• The current treatment paradigm for diabetic nephropathy relies on early detection, glycaemic control, and tight blood pressure management with preferential use of RAAS blockade 5.
• The use of ACE inhibitors or ARBs is recommended for patients with diabetic nephropathy, particularly those with hypertension and/or proteinuria, to hinder renal disease progression 6, 7.
• Combination therapy with ACE inhibitors and ARBs may slow the progression of microalbuminuria to clinical albuminuria, although more research is needed to confirm this 7.

Gaps in Treatment

• Despite the availability of effective treatments, there is a significant underuse of ACE inhibitors and ARBs among patients with diabetic nephropathy, highlighting the need for quality-improvement interventions 6.
• Only 50% of patients with diabetic nephropathy receive the recommended treatment with ACE inhibitors or ARBs, providing an opportunity for improved clinical outcomes 6.