What is the management of diabetic nephropathy?

Management of Diabetic Nephropathy

The cornerstone of diabetic nephropathy management includes ACE inhibitors or ARBs as first-line therapy, SGLT2 inhibitors, glycemic control, blood pressure management, and lifestyle modifications to reduce mortality and improve quality of life. 1

Pharmacological Interventions

Renin-Angiotensin System Inhibition

• Initiate ACE inhibitors or ARBs in patients with diabetes, hypertension, and albuminuria, titrating to the highest tolerated dose 2
• For type 1 diabetic patients with any degree of albuminuria, ACE inhibitors delay progression of nephropathy 2
• For type 2 diabetic patients with microalbuminuria, both ACE inhibitors and ARBs delay progression to macroalbuminuria 2
• For type 2 diabetic patients with macroalbuminuria and renal insufficiency (serum creatinine >1.5 mg/dl), ARBs are specifically indicated to delay nephropathy progression 3
• If one class is not tolerated, substitute with the other class 2
• Avoid combining ACE inhibitors and ARBs as this increases risk of hyperkalemia and acute kidney injury without additional benefits 3

Newer Agents

• Add SGLT2 inhibitors for patients with type 2 diabetes and CKD with eGFR ≥30 mL/min/1.73 m² due to significant renoprotective effects 2
• Consider long-acting GLP-1 receptor agonists for patients not achieving glycemic targets despite metformin and SGLT2 inhibitor use 2

Glycemic Management

• Target individualized HbA1c ranging from <6.5% to <8.0% based on hypoglycemia risk 2
• First-line treatment for type 2 diabetes with CKD should include metformin (if eGFR ≥30 mL/min/1.73 m²) and an SGLT2 inhibitor 2
• Monitor HbA1c regularly, but be aware that its accuracy may decrease when eGFR falls below 30 mL/min/1.73 m² 2
• Consider continuous glucose monitoring for patients on dialysis or when HbA1c may be unreliable 2

Blood Pressure Management

• Target blood pressure <130/80 mmHg in patients with diabetes and CKD 1
• Titrate antihypertensive medications to the highest tolerated dose 2
• For patients unable to tolerate ACE inhibitors or ARBs, consider non-dihydropyridine calcium channel blockers, β-blockers, or diuretics 2
• Monitor serum potassium and creatinine within 2-4 weeks after initiating or changing dose of RAS inhibitors 2

Dietary and Lifestyle Modifications

• Maintain protein intake at 0.8 g/kg body weight/day for patients not on dialysis 2
• Consider further restriction to 0.6 g/kg/day when GFR begins to decline 2
• Increase protein intake to 1.0-1.2 g/kg/day for patients on dialysis 1
• Limit sodium intake to <2 g sodium per day (<5 g sodium chloride) 2
• Recommend moderate-intensity physical activity for at least 150 minutes per week 2
• Advise patients who use tobacco to quit 2
• Promote a balanced diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, and unsaturated fats 2

Monitoring and Follow-up

• Screen annually for microalbuminuria in type 1 diabetic patients who have had diabetes for 5 years and all type 2 diabetic patients starting at diagnosis 2
• Monitor kidney function (eGFR) at least annually, with more frequent monitoring for advancing CKD 1
• When GFR begins to decline substantially, refer to a nephrologist 2
• Refer patients with eGFR <30 mL/min/1.73 m², uncertain etiology of kidney disease, difficult management issues, or rapidly progressing kidney disease to a nephrologist 1

Management of Complications

• For hyperkalemia on RAS inhibitors, consider moderating potassium intake, initiating diuretics, using sodium bicarbonate for metabolic acidosis, or adding gastrointestinal cation exchangers 1
• Use sodium and phosphate restriction and phosphate binders when indicated for progressive renal disease 2
• Carefully hydrate azotemic patients before procedures requiring radiocontrast media, as these are particularly nephrotoxic in diabetic nephropathy 2

Common Pitfalls to Avoid

• Don't discontinue RAS inhibitors for minor increases in serum creatinine (≤30%) in the absence of volume depletion 1
• Don't use NSAIDs in patients with diabetic nephropathy as they may cause deterioration of renal function 3
• Don't delay nephrology referral for patients with eGFR <30 mL/min/1.73 m² or rapidly declining kidney function 1
• Don't ignore the need for medication adjustment when eGFR declines, particularly for glycemic medications 1
• Don't combine lithium with ARBs without careful monitoring of lithium levels 3