What is the treatment for diabetic (dm) nephropathy?

From the Guidelines

The treatment for diabetic nephropathy should focus on slowing disease progression and preventing end-stage renal disease, with a cornerstone of therapy including optimizing glycemic control and blood pressure management, and the use of medications such as ACEIs, ARBs, and SGLT2 inhibitors, as supported by the most recent study 1. The goal of treatment is to reduce morbidity, mortality, and improve quality of life. Key components of therapy include:

• Optimizing glycemic control with a target HbA1c of less than 7%
• Blood pressure management with a goal of less than 130/80 mmHg
• Use of first-line medications such as:

• Angiotensin-converting enzyme inhibitors (ACEIs) like lisinopril (10-40 mg daily)
• Angiotensin II receptor blockers (ARBs) such as losartan (50-100 mg daily)
• SGLT2 inhibitors like empagliflozin (10-25 mg daily) or dapagliflozin (5-10 mg daily), which have shown significant renal protective effects and should be added regardless of glycemic control status, as shown in a study published in 2019 1

• Lifestyle modifications, including:

• Dietary sodium restriction (<2,300 mg/day)
• Moderate protein intake (0.8 g/kg/day)
• Regular physical activity Regular monitoring of kidney function, albuminuria, and electrolytes is necessary, especially when initiating or adjusting medication doses. These interventions work synergistically to reduce glomerular hyperfiltration, decrease inflammation, and minimize oxidative stress that contributes to diabetic kidney damage. According to a recent review 1, the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists is recommended for patients with diabetic kidney disease to provide both kidney and cardiovascular protective benefits.

From the FDA Drug Label

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)

The treatment for diabetic (dm) nephropathy is losartan, which reduces the rate of progression of nephropathy in patients with type 2 diabetes and a history of hypertension 2.

• Key benefits of losartan in this population include:
  • Reducing the risk of doubling of serum creatinine
  • Reducing the risk of end stage renal disease (need for dialysis or renal transplantation)
• Patient selection: losartan is indicated for patients with type 2 diabetes, a history of hypertension, elevated serum creatinine, and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g)

From the Research

Treatment Options for Diabetic Nephropathy

The treatment for diabetic nephropathy involves a combination of lifestyle modifications and pharmacological interventions. The primary goals of treatment are to slow the progression of kidney disease, control blood pressure, and reduce proteinuria.

• Angiotensin-Converting Enzyme (ACE) Inhibitors: ACE inhibitors, such as lisinopril, have been shown to reduce the progression of renal disease in patients with diabetes 3, 4. They work by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor that can damage kidney tissues.
• Angiotensin II Receptor Blockers (ARBs): ARBs, such as losartan, have also been shown to reduce microalbuminuria and slow the progression of kidney disease in patients with diabetes 3, 5. They work by blocking the action of angiotensin II on its receptors, reducing blood pressure and proteinuria.
• Combination Therapy: Combination therapy with an ACE inhibitor and an ARB may provide additional benefits in reducing proteinuria and slowing the progression of kidney disease 6. However, this approach should be used with caution, as it may increase the risk of hyperkalemia and acute kidney injury.
• Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors: SGLT2 inhibitors, such as empagliflozin, may have renoprotective effects beyond their glucose-lowering properties 7. They work by reducing sodium reabsorption in the proximal tubule, decreasing glomerular hyperfiltration and proteinuria.
• Blood Pressure Control: Controlling blood pressure is essential in slowing the progression of kidney disease in patients with diabetes. The use of ACE inhibitors, ARBs, and other antihypertensive agents can help achieve this goal 3, 5.
• Glycemic Control: Tight glycemic control is also important in preventing the progression of kidney disease in patients with diabetes. The use of glucose-lowering agents, such as SGLT2 inhibitors, can help achieve this goal 7.

Key Considerations

When treating diabetic nephropathy, it is essential to consider the following factors:

• Monitoring of kidney function: Regular monitoring of kidney function, including serum creatinine and urine protein levels, is crucial in assessing the effectiveness of treatment and detecting potential adverse effects.
• Blood pressure control: Controlling blood pressure is essential in slowing the progression of kidney disease.
• Glycemic control: Tight glycemic control is important in preventing the progression of kidney disease.
• Potential adverse effects: The use of ACE inhibitors, ARBs, and SGLT2 inhibitors can be associated with potential adverse effects, such as hyperkalemia, acute kidney injury, and hypoglycemia.