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For further information, see CMDT Part 24-19: Diabetic Nephropathy
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Most common cause of end-stage kidney disease (ESKD) in United States
Evidence of diabetes mellitus, typically over 10 years
Incidence of chronic kidney disease (CKD) is about 30% in both types 1 and 2 diabetes mellitus
Males, African Americans, and Native Americans are at higher risk
Those with a family history of kidney disease are at higher risk
Albuminuria usually precedes decline in glomerular filtration rate (GFR)
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Diabetic retinopathy is common
Develops about 10 years after the onset of diabetes mellitus
May be present at the time type 2 diabetes mellitus is diagnosed
Kidney size usually enlarged until disease becomes advanced
Patients with diabetes prone to other kidney diseases, such as
Papillary necrosis
Chronic interstitial nephritis
Type 4 (hyporeninemic hypoaldosteronemic) renal tubular acidosis
Acute kidney injury (AKI) from many insults (eg, intravenous contrast material and concomitant use of an angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker [ARB] with nonsteroidal anti-inflammatory drug [NSAID])
Mortality rates are higher for patients with diabetes and kidney disease compared to those without CKD
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First stage of diabetic nephropathy is hyperfiltration, with an increase in GFR, followed by the development of moderate albuminuria (30–300 mg/d)
With progression, albuminuria increases to severe (> 300 mg/d) and can be detected on urine dipstick as overt proteinuria; GFR subsequently declines over time
Yearly screening for moderate albuminuria is recommended for all patients with diabetes; diabetic nephropathy less commonly can present as nonproteinuric CKD
Renal biopsy is not required in most patients unless atypical findings are present, such as
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Moderate albuminuria requires aggressive treatment
Strict glycemic control should be emphasized early, with recognition of risk of hypoglycemia as CKD becomes advanced
Blood pressure goals should be tailored:
ACCORD trial: blood pressure lowering below 140/90 mm Hg in patients with moderate albuminuria (30–300 mg/d) and preserved GFR and those with significant cardiovascular disease did not confer survival benefit
2021 Kidney Disease Improving Global Outcomes practice guidelines: targeting < 120/80 mm Hg in patients with diabetes and CKD, regardless of degree of albuminuria
ACE inhibitors and ARBs
Recommended in those with moderate albuminuria to
Not absolutely indicated in diabetic patients without albuminuria
With initiation or up titration of therapy, close monitoring within ∼2 weeks to exclude resultant hyperkalemia or decline in GFR of > 30%
Combination ARB and ACE inhibitor therapy is not recommended due to lack of efficacy and increased adverse events (hyperkalemia and AKI)
Canagliflozin, empagliflozin, and dapagliflozin (sodium glucose cotransporter 2 [or SGLT-2] inhibitors)