Treatment and prevention of diabetic nephropathy

Diabetic nephropathy

Diabetic nephropathy is treated with medicines that lower blood pressure and protect the kidneys. These medicines may slow down kidney damage and are started as soon as any amount of protein is found in the urine (microalbuminuria). The use of these medicines before nephropathy occurs may also help prevent nephropathy in people who have normal blood pressure.

Diabetic nephropathy is the leading cause of chronic kidney disease in patients starting renal replacement therapy (1) and is associated with increased cardiovascular mortality (2). Diabetic nephropathy has been classically defined by the presence of proteinuria >0.5 g/24 h. This stage has been referred to as overt nephropathy, clinical nephropathy, proteinuria, or macroalbuminuria. In the early 1980s, seminal studies from Europe revealed that small amounts of albumin in the urine, not usually detected by conventional methods, were predictive of the later development of proteinuria in type 1 (3–5) and type 2 (6) diabetic patients. This stage of renal involvement was termed microalbuminuria or incipient nephropathy.

If you have high blood pressure, two or more medicines may be needed to lower your blood pressure enough to protect the kidneys. Medicines are added one at a time as needed.

If you take other medicines, avoid ones that damage or stress the kidneys, especially nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include ibuprofen and naproxen.

Diabetic nephropathy has been didactically categorized into stages based on the values of urinary albumin excretion (UAE): microalbuminuria and macroalbuminuria. The cutoff values adopted by the American Diabetes Association (14) (timed, 24-h, and spot urine collection) for the diagnosis of micro- and macroalbuminuria, as well as the main clinical features of each stage, are depicted in Table 1. There is accumulating evidence suggesting that the risk for developing diabetic nephropathy (15–18) and cardiovascular disease (19,20) starts when UAE values are still within the normoalbuminuric range. Progression to micro- or macroalbuminuria was more frequent in patients with type 2 diabetes with baseline UAE above the median (2.5 mg/24 h) (15). After 10 years of follow-up, the risk of diabetic nephropathy was 29 times greater in patients with type 2 diabetes with UAE values >10 μg/min (16). The same was true for patients with type 1 diabetes (17). This favors the concept that the risk associated with UAE is a continuum, as is the case with blood pressure levels (21). Possibly, values of UAE lower than those currently used for microalbuminuria diagnosis should be established.

It is also important to keep your blood sugar within your target range. Maintaining blood sugar levels within your target range prevents damage to the small blood vessels in the kidneys.

Limiting the amount of salt in your diet can help keep your high blood pressure from getting worse. You may also want to restrict the amount of protein in your diet. If diabetes has affected your kidneys, limiting how much protein you eat may help you preserve kidney function. Talk to your doctor or dietitian about how much protein is best for you.

Initial treatment
Medicines that are used to treat diabetic nephropathy are also used to control blood pressure. If you have a very small amount of protein in your urine, these medicines may reverse the kidney damage. Medicines used for initial treatment of diabetic nephropathy include:

Angiotensin-converting enzyme (ACE) inhibitors, such as captopril, enalapril, lisinopril, and ramipril. ACE inhibitors can lower the amount of protein being lost in the urine. Also, they may reduce your risk of heart and blood vessel (cardiovascular) disease.
Angiotensin II receptor blockers (ARBs), such as candesartan cilexetil, irbesartan, losartan potassium, and telmisartan. You may be given both an ACE inhibitor and an ARB. The combination of these medicines may provide greater protection for your kidneys than either medicine alone.
If you also have high blood pressure, two or more medicines may be needed to lower your blood pressure enough to protect your kidneys. Medicines are added one at a time as needed.

If you take other medicines, avoid ones that damage or stress the kidneys, especially nonsteroidal anti-inflammatory drugs (NSAIDs).

It is also important to keep your blood sugar within your target range to prevent damage to the small blood vessels in the kidneys.

Ongoing treatment
As diabetic nephropathy progresses, blood pressure usually rises, making it necessary to add more medicine to control blood pressure.

Your doctor may advise you to take the following medicines that lower blood pressure. You may need to take different combinations of these medicines to best control your blood pressure. By lowering your blood pressure, you may reduce your risk of kidney damage. Medicines include:

A combination of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). A combination of these medicines may be more effective in controlling blood pressure than either used alone.

Calcium channel blockers, which lower blood pressure by making it easier for blood to flow through the vessels. Examples include amlodipine, diltiazem, or verapamil.
Diuretics. Medicines such as chlorthalidone, hydrochlorothiazide, or spironolactone help lower blood pressure by removing sodium and water from the body.

Beta-blockers lower blood pressure by slowing down your heartbeat and reducing the amount of blood pumped with each heartbeat. Examples include atenolol, carvedilol, or metoprolol.

Continue to avoid other medicines that may damage or stress the kidneys, especially nonsteroidal anti-inflammatory drugs (NSAIDs). And it is still important to keep your blood sugar within your target range, eat healthy foods, get regular exercise, and not smoke.

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