Diabetic nephropathy medical therapy: Difference between revisions
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{{Diabetic nephropathy}} | {{Diabetic nephropathy}} | ||
{{CMG}} | {{CMG}}; {{AE}}{{DN}} | ||
==Overview== | ==Overview== | ||
The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is [[ACE inhibitor]] drugs, which usually | The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is [[ACE inhibitor]] drugs, which usually reduce glomerular hypertension, [[proteinuria]] levels, [[systemic hypertension]] and slow the progression of diabetic nephropathy. | ||
==Medical Therapy== | ==Medical Therapy== | ||
See [[Diabetic nephropathy secondary prevention]] | |||
* [[ACE inhibitors]] and [[ARB's]] are the drug of choice for controlling [[hypertension]] in diabetic nephropathy. Some advantages include: | |||
===Lifestyle Modifications=== | |||
The management of diabetic nephropathy depends a lot on lifestyle and dietary modifications.These include:<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref> | |||
*[[Weight loss]] | |||
*Exercise | |||
*[[Smoking cessation]] | |||
*Reduction of salt and alcohol intake | |||
*Limiting protein intake to less than 0.8 g per kg per day | |||
===Blood Pressure Control=== | |||
[[Blood pressure]] in diabetic patients with [[nephropathy]] is aimed at levels of less than 130/80.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid11403001">{{cite journal |vauthors= |title=American Diabetes Association Clinical Practice Recommendations 2001 |journal=Diabetes Care |volume=24 Suppl 1 |issue= |pages=S1–133 |year=2001 |pmid=11403001 |doi= |url=}}</ref><ref name="pmid9834731">{{cite journal |vauthors=Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale JF, Zinman B, Lillie D |title=1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association |journal=CMAJ |volume=159 Suppl 8 |issue= |pages=S1–29 |year=1998 |pmid=9834731 |pmc=1255890 |doi= |url=}}</ref> | |||
*[[ACE inhibitors]] and [[ARB's]] are the drug of choice for controlling [[hypertension]] in diabetic nephropathy.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref><ref name="pmid26928912">{{cite journal |vauthors=Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A |title=Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes |journal=Ann. Intern. Med. |volume=164 |issue=8 |pages=542–52 |year=2016 |pmid=26928912 |doi=10.7326/M15-3016 |url=}}</ref> Aggressive treatment of [[hypertension]] is found to retard the progression of damage to nephrons secondary to [[diabetes]]. Some advantages include: | |||
** Lowering [[systemic hypertension]]. | ** Lowering [[systemic hypertension]]. | ||
** Lowering glomerular hypertension. | ** Lowering glomerular hypertension. | ||
** Dilatation of systemic and renal arterioles, increasing [[renal blood flow]]. | ** Dilatation of systemic and renal arterioles, increasing [[renal blood flow]]. | ||
** Rise in [[kinins]] which is also responsible for some of the side effects such as dry cough.[http://www.ksu.edu.sa/sites/Colleges/Medicine/Lists/Medical%20Subjects/Flat.aspx?RootFolder=http%3a%2f%2fwww%2eksu%2eedu%2esa%2fsites%2fColleges%2fMedicine%2fLists%2fMedical%20Subjects%2fDiabetes%20Mellitus%20and%20Angiotensin%20Converting%20Enzyme%20Inhibitors&FolderCTID=0x01200200CEDE56CEF8D11C46824F2F6116DF88AA] | ** Rise in [[kinins]] which is also responsible for some of the side effects such as dry cough.[http://www.ksu.edu.sa/sites/Colleges/Medicine/Lists/Medical%20Subjects/Flat.aspx?RootFolder=http%3a%2f%2fwww%2eksu%2eedu%2esa%2fsites%2fColleges%2fMedicine%2fLists%2fMedical%20Subjects%2fDiabetes%20Mellitus%20and%20Angiotensin%20Converting%20Enzyme%20Inhibitors&FolderCTID=0x01200200CEDE56CEF8D11C46824F2F6116DF88AA]<br> | ||
* [[ACEI]] and [[ARBs]] should not be combined due to increased risk of [[hyperkalemia]] and [[acute kidney injury]] ([[AKI]]).<ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref><ref name="pmid26928912">{{cite journal |vauthors=Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A |title=Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes |journal=Ann. Intern. Med. |volume=164 |issue=8 |pages=542–52 |year=2016 |pmid=26928912 |doi=10.7326/M15-3016 |url=}}</ref> | |||
[[ | |||
[[ | **[[Aldosterone antagonists]]: found to decrease blood pressure as well as [[proteinuria]], whether used alone or in combination with an [[ACEI]]/[[ARB]]. However, when used in combination with the other drugs, patients should be monitored for [[hyperkalemia]].<ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref> | ||
**Other drugs, such as [[beta blockers]], [[calcium channel blockers]] and [[diuretics]] may be added if [[blood pressure]] is not well controlled.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid26928912">{{cite journal |vauthors=Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A |title=Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes |journal=Ann. Intern. Med. |volume=164 |issue=8 |pages=542–52 |year=2016 |pmid=26928912 |doi=10.7326/M15-3016 |url=}}</ref> | |||
=== | ===Lipid Therapy=== | ||
* The use of [[statins]] decreases the risk of [[cardiovascular disease]] and slows the loss of renal function.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid9742977">{{cite journal |vauthors= |title=Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group |journal=Lancet |volume=352 |issue=9131 |pages=854–65 |year=1998 |pmid=9742977 |doi= |url=}}</ref> | |||
* | * For diabetic patients over the age of 40 with diabetic nephropathy, [[statins]] are recommended regardless of baseline [[lipid]] levels.<ref name="pmid25342915">{{cite journal |vauthors=Lim AKh |title=Diabetic nephropathy - complications and treatment |journal=Int J Nephrol Renovasc Dis |volume=7 |issue= |pages=361–81 |year=2014 |pmid=25342915 |pmc=4206379 |doi=10.2147/IJNRD.S40172 |url=}}</ref><ref name="pmid11466120">{{cite journal |vauthors=Gerstein HC, Mann JF, Yi Q, Zinman B, Dinneen SF, Hoogwerf B, Hallé JP, Young J, Rashkow A, Joyce C, Nawaz S, Yusuf S |title=Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals |journal=JAMA |volume=286 |issue=4 |pages=421–6 |year=2001 |pmid=11466120 |doi= |url=}}</ref> | ||
===Dialysis=== | |||
* [[Dialysis]] may be necessary once end-stage renal disease develops. | |||
==References== | ==References== | ||
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{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 13:04, 16 June 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]
Overview
The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is ACE inhibitor drugs, which usually reduce glomerular hypertension, proteinuria levels, systemic hypertension and slow the progression of diabetic nephropathy.
Medical Therapy
See Diabetic nephropathy secondary prevention
Lifestyle Modifications
The management of diabetic nephropathy depends a lot on lifestyle and dietary modifications.These include:[1]
- Weight loss
- Exercise
- Smoking cessation
- Reduction of salt and alcohol intake
- Limiting protein intake to less than 0.8 g per kg per day
Blood Pressure Control
Blood pressure in diabetic patients with nephropathy is aimed at levels of less than 130/80.[1][2][3]
- ACE inhibitors and ARB's are the drug of choice for controlling hypertension in diabetic nephropathy.[1][4][5] Aggressive treatment of hypertension is found to retard the progression of damage to nephrons secondary to diabetes. Some advantages include:
- Lowering systemic hypertension.
- Lowering glomerular hypertension.
- Dilatation of systemic and renal arterioles, increasing renal blood flow.
- Rise in kinins which is also responsible for some of the side effects such as dry cough.[3]
- ACEI and ARBs should not be combined due to increased risk of hyperkalemia and acute kidney injury (AKI).[4][5]
- Aldosterone antagonists: found to decrease blood pressure as well as proteinuria, whether used alone or in combination with an ACEI/ARB. However, when used in combination with the other drugs, patients should be monitored for hyperkalemia.[4]
- Other drugs, such as beta blockers, calcium channel blockers and diuretics may be added if blood pressure is not well controlled.[1][5]
Lipid Therapy
- The use of statins decreases the risk of cardiovascular disease and slows the loss of renal function.[1][6]
- For diabetic patients over the age of 40 with diabetic nephropathy, statins are recommended regardless of baseline lipid levels.[4][7]
Dialysis
- Dialysis may be necessary once end-stage renal disease develops.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Remuzzi G, Schieppati A, Ruggenenti P (2002). "Clinical practice. Nephropathy in patients with type 2 diabetes". N. Engl. J. Med. 346 (15): 1145–51. doi:10.1056/NEJMcp011773. PMID 11948275.
- ↑ "American Diabetes Association Clinical Practice Recommendations 2001". Diabetes Care. 24 Suppl 1: S1–133. 2001. PMID 11403001.
- ↑ Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale JF, Zinman B, Lillie D (1998). "1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association". CMAJ. 159 Suppl 8: S1–29. PMC 1255890. PMID 9834731.
- ↑ 4.0 4.1 4.2 4.3 Lim A (2014). "Diabetic nephropathy - complications and treatment". Int J Nephrol Renovasc Dis. 7: 361–81. doi:10.2147/IJNRD.S40172. PMC 4206379. PMID 25342915. Vancouver style error: initials (help)
- ↑ 5.0 5.1 5.2 Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A (2016). "Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes". Ann. Intern. Med. 164 (8): 542–52. doi:10.7326/M15-3016. PMID 26928912.
- ↑ "Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group". Lancet. 352 (9131): 854–65. 1998. PMID 9742977.
- ↑ Gerstein HC, Mann JF, Yi Q, Zinman B, Dinneen SF, Hoogwerf B, Hallé JP, Young J, Rashkow A, Joyce C, Nawaz S, Yusuf S (2001). "Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals". JAMA. 286 (4): 421–6. PMID 11466120.