From the Guidelines
The most common cause of needing renal transplantation is end-stage renal disease (ESRD) resulting from diabetic nephropathy, with diabetes mellitus being the leading cause of ESRD worldwide, accounting for approximately half of all new cases of kidney failure. According to the most recent and highest quality study, 1, diabetes is the most common cause of kidney failure requiring kidney transplantation or dialysis worldwide, with the prevalence of CKD among people with diabetes being over 25%. The study also highlights that diabetes fueled a marked increase in the prevalence of kidney failure over the last 30 years and now accounts for half of all new cases of kidney failure in the United States.
Key Points
- Diabetes mellitus, particularly type 2 diabetes, leads to progressive kidney damage through mechanisms including glomerular hyperfiltration, basement membrane thickening, and mesangial expansion.
- Hypertension often accompanies and accelerates diabetic kidney disease, making blood pressure control essential in management.
- Other significant causes of ESRD include hypertensive nephrosclerosis, glomerulonephritis, polycystic kidney disease, and interstitial nephritis.
- Prevention strategies focus on tight glycemic control (maintaining HbA1c below 7%), blood pressure management (target <130/80 mmHg), and use of medications like ACE inhibitors or ARBs that provide renoprotection.
- Regular screening for early signs of kidney damage through urine albumin testing and estimated glomerular filtration rate (eGFR) monitoring is crucial for those with risk factors, as supported by studies such as 1 and 1.
Management and Prevention
The management and prevention of diabetic nephropathy require a multifaceted approach, including lifestyle modifications, medication, and regular monitoring. The American Diabetes Association and Kidney Disease: Improving Global Outcomes (KDIGO) recommend a comprehensive approach to diabetes management in patients with CKD, including tight glycemic control, blood pressure management, and use of medications that provide renoprotection, as outlined in 1. Additionally, studies such as 1 highlight the importance of continuous glucose monitoring (CGM) for glycemic monitoring in patients with advanced CKD.
From the Research
Causes of Renal Transplantation
- Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) worldwide, as stated in studies 2, 3, 4, 5, 6.
- Hypertensive nephropathy, often in combination with diabetic nephropathy, is also a common cause of ESRD 3.
- The development of diabetic nephropathy is characterized by chronic hyperglycemia and high blood pressure, with screening for microalbuminuria being a crucial step in diagnosis 6.
Prevalence and Impact
- Diabetic nephropathy is a major complication of both type 1 and type 2 diabetes, markedly enhancing the risk of cardiovascular events 4.
- The presentation of diabetic kidney disease can vary, especially in patients with type 2 diabetes, where concomitant presence of other glomerular/tubular pathologies and severe peripheral vascular disease can become important confounders 5.
- All-cause mortality in individuals with diabetic kidney disease is approximately 30 times higher than that in diabetic patients without nephropathy 5.
Management and Treatment
- Management of metabolic and hemodynamic perturbations is crucial for the prevention and delay of progression of diabetic kidney disease 5.
- Standard therapy includes blood glucose and blood pressure control using the renin-angiotensin system blockade, targeting A1c < 7%, and <130/80 mmHg 6.
- Regression of albuminuria remains an important therapeutic goal, with additional therapies such as vitamin D receptor activators, incretin-related drugs, and therapies that target inflammation being promising for the prevention of diabetic nephropathy progression 6.