Prevention of diabetic nephropathy

Early Diabetes

Diabetic nephropathy is becoming increasingly common with the aging of our population and the obesity epidemic. The major ways to prevent or slow its progression are by reducing blood pressure, controlling blood sugar, and inhibiting the renin-angiotensin-aldosterone axis. New therapeutic agents are also being tried.

The progression from no proteinuria to microalbuminuria to clinical proteinuria parallels glomerular changes of thickening of the basement membrane, mesangial expansion, and the development of Kimmelstiel-Wilson nodules and sclerosis.

Blood pressure control to 130/80 mm Hg slows microvascular and macrovascular disease, but the goal should not be lower in older patients with diabetes.

Glycemic control slows microvascular disease: the goal for most patients for hemoglobin A1c is 7.0%. Tighter control may increase cardiovascular risk.

Either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker is the first-line treatment for diabetic nephropathy; combining the two is no longer recommended.

If more aggressive treatment is needed, a diuretic or spironolactone (with potassium monitoring) can be added.

The role of sodium bicarbonate and new agents such as blockers of transcription factors is still emerging.

Keeping your blood sugar tightly controlled every day is a big commitment. It requires constant monitoring and, if you take insulin, frequent doses of medication. But keeping your blood sugar as close to normal as possible is the best way to help prevent neuropathy and other complications of diabetes. Consistency is important because shifts in blood sugar levels can accelerate nerve damage.

For the best control, aim for a blood glucose level from 70 to 130 mg/dL (3.9 to 7.2 mmol/L) before meals and an A1C reading that is less than 7 percent. An A1C test measures your average blood sugar level over a period of two to three months. The American Diabetes Association recommends that people with diabetes have an A1C test at least twice a year if blood sugar levels are consistently in a healthy range. If your blood sugar isn't well controlled or you change medications, get tested more often.

Early in the course of diabetic nephropathy, blood pressure is normal and microalbuminuria is not evident, but many patients have a high glomerular filtration rate (GFR), indicating temporarily “enhanced” renal function or hyperfiltration. The next stage is characterized by microalbuminuria, correlating with glomerular mesangial expansion: the GFR falls back into the normal range and blood pressure starts to increase. Finally, macroalbuminuria occurs, accompanied by rising blood pressure and a declining GFR, correlating with the histologic appearance of glomerulosclerosis and Kimmelstiel-Wilson nodules.4

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