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| ==Secondary Prevention== | | ==Secondary Prevention== |
| Once diabetic nephropathy develops, secondary prevention to halt the progression of the disease is aimed at: | | Once diabetic nephropathy develops, secondary prevention to halt the progression of the disease is aimed at: |
| * Regarding inhibition of the [[renin-angiotensin system]] with [[ACE inhibitor]]s or [[renin inhibitor]]s, the [[Cochrane Collaboration]] reported reduction in renal outcomes<ref name="pmid17054288">{{cite journal| author=Strippoli GF, Bonifati C, Craig M, Navaneethan SD, Craig JC| title=Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease. | journal=Cochrane Database Syst Rev | year= 2006 | volume= | issue= 4 | pages= CD006257 | pmid=17054288 | doi=10.1002/14651858.CD006257 | pmc=6956646 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17054288 }} </ref>. This includes a regression to normoalbuminuria (in analysis 1.6 regression was found in 201/995 [20%]; risk ratio 3.06). | | * [[Renin-angiotensin-aldosterone system]] RAAS with [[ACE inhibitor]]s or [[angiotensin II receptor antagonist]]s, the [[Cochrane Collaboration]] reported a reduction in renal outcomes. This includes a regression to normoalbuminuria (in analysis 1.6 regression was found in 201/995 [20%]; risk ratio 3.06). |
| ** Per the Cochrane, this benefit is not affected by moderately increased albuminuria (30 to 300 mg/day; A2 or microalbuminuria) or severely increased albuminuria (>300 mg/day; A3 or microalbuminuria)<ref name="pmid17054288"/> | | ** Per the Cochrane, this benefit is not affected by moderately increased albuminuria (30 to 300 mg/day; A2 or microalbuminuria) or severely increased albuminuria (>300 mg/day; A3 or microalbuminuria) |
| ** Whether this applies to patients without hypertension is unclear:
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| *** The Cochrane reported, "presence (versus absence) of [[hypertension]] in the enrolled populations did not significantly impact...doubling of serum creatinine (interaction P value = 0.22)"<ref name="pmid17054288"/> However, the Cochrane did not report the data underlying this analysis.
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| *** The KDIGO guideline reports that only two trials included patients without [[hypertension]] (RENAAL<ref name="pmid11565518">{{cite journal| author=Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH | display-authors=etal| title=Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 12 | pages= 861-9 | pmid=11565518 | doi=10.1056/NEJMoa011161 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11565518 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=11985425 Review in: ACP J Club. 2002 May-Jun;136(3):82-4] </ref> and INNOVATION<ref name="pmid18633177">{{cite journal| author=Makino H, Haneda M, Babazono T, Moriya T, Ito S, Iwamoto Y | display-authors=etal| title=Microalbuminuria reduction with telmisartan in normotensive and hypertensive Japanese patients with type 2 diabetes: a post-hoc analysis of The Incipient to Overt: Angiotensin II Blocker, Telmisartan, Investigation on Type 2 Diabetic Nephropathy (INNOVATION) study. | journal=Hypertens Res | year= 2008 | volume= 31 | issue= 4 | pages= 657-64 | pmid=18633177 | doi=10.1291/hypres.31.657 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18633177 }} </ref>). The INNOVATION trial reported significant reduction in urine microalbuminuria from [[telmisartan]] regardless of whether hypertension was present<ref name="pmid18633177"/>.
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| * Regarding inhibitors of [[sodium-glucose co-transporter 2]]:
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| ** [[Canagliflozin]] educes the risk of kidney failure and cardiovascular events in the CREDENCE [[randomized control trial]] of patients with diabetic kidney disease (urinary albumin-to-creatinine ratio > 300) who were almost all hypertensive and already taking [[ACE inhibitor]]s.<ref name="pmid30990260">{{cite journal| author=Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJL, Charytan DM | display-authors=etal| title=Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. | journal=N Engl J Med | year= 2019 | volume= 380 | issue= 24 | pages= 2295-2306 | pmid=30990260 | doi=10.1056/NEJMoa1811744 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30990260 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=31366588 Review in: BMJ Evid Based Med. 2020 Apr;25(2):79-80] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=31426058 Review in: Ann Intern Med. 2019 Aug 20;171(4):JC15] </ref>.
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| ** [[Empagliflozin]], in the EMPA-REG trial reduced renal outcomes even with patients with cardiovascular disease 80% also taking [[ACE inhibitor]]s or [[renin inhibitor]]s, whose urinary albumin-to-creatinine ratio < 30<ref name="pmid27299675">{{cite journal| author=Wanner C, Inzucchi SE, Lachin JM, Fitchett D, von Eynatten M, Mattheus M | display-authors=etal| title=Empagliflozin and Progression of Kidney Disease in Type 2 Diabetes. | journal=N Engl J Med | year= 2016 | volume= 375 | issue= 4 | pages= 323-34 | pmid=27299675 | doi=10.1056/NEJMoa1515920 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27299675 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=27750299 Review in: Ann Intern Med. 2016 Oct 18;165(8):JC39] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=28159856 Review in: Evid Based Med. 2017 Apr;22(2):69-70] </ref> Among patients with no albuminuria (urinary albumin-to-creatinine ratio, <30 at baseline), empagliflozin did not reduce incident albuminuria (urinary albumin-to-creatinine ratio, ≥30).
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| ** It is not clear why the KDIGO guidelines recommend SGLT2i for all patients with albuminuria when some patients taking [[ACE inhibitor]]s only will have regression to normoalbuminuria.
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| * Regarding [[mineralocorticoid receptor]] antagonists (MRAs), the FIDELIO-DKD<ref name="pmid33264825">{{cite journal| author=Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P | display-authors=etal| title=Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. | journal=N Engl J Med | year= 2020 | volume= 383 | issue= 23 | pages= 2219-2229 | pmid=33264825 | doi=10.1056/NEJMoa2025845 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33264825 }} </ref> and the FIGARO-DKD<ref name="pmid34449181">{{cite journal| author=Pitt B, Filippatos G, Agarwal R, Anker SD, Bakris GL, Rossing P | display-authors=etal| title=Cardiovascular Events with Finerenone in Kidney Disease and Type 2 Diabetes. | journal=N Engl J Med | year= 2021 | volume= 385 | issue= 24 | pages= 2252-2263 | pmid=34449181 | doi=10.1056/NEJMoa2110956 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34449181 }} </ref> trials have been conducted:
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| **
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| * The benefits of tight control of blood glucose levels are uncertain per a [[systematic review]] by the [[Cochrane Collaboration]]<ref name="pmid28594069">{{cite journal| author=Ruospo M, Saglimbene VM, Palmer SC, De Cosmo S, Pacilli A, Lamacchia O | display-authors=etal| title=Glucose targets for preventing diabetic kidney disease and its progression. | journal=Cochrane Database Syst Rev | year= 2017 | volume= 6 | issue= | pages= CD010137 | pmid=28594069 | doi=10.1002/14651858.CD010137.pub2 | pmc=6481869 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28594069 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=29049766 Review in: Ann Intern Med. 2017 Oct 17;167(8):JC47] [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=29097446 Review in: Evid Based Med. 2017 Dec;22(6):219-220] </ref>.
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| * Strict control of [[blood pressure]], as well as [[lipids]].<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>
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| ==References== | | ==References== |