Prevention of DKD in diabetic, normoalbuminuric patients
Prevention of DKD in these patients is based on a strict control of the known risk factors: blood sugar levels, hypertension, dyslipidemia, smoking.
Blood sugar levels
Strict control of the blood sugar levels has a significant impact in the prevention of DKD in diabetic patients.
According to several clinical trials, Hb A1c (glycated hemoglobin) levels <7% are associated with decreased risk for clinical and structural manifestations of diabetic nephropathy in type 1 and type 2 diabetic patients.
The Hb A1c test measures what percentage of the hemoglobin (the protein in red blood cells that carries oxygen) is coated with sugar (glycated). The higher the Hb A1c level, the poorer the blood sugar control and the higher the risk of diabetes complications. The hemoglobin A1c test tells you your average level of blood sugar over the past two to three months and it can help patients to see if their blood sugar levels are staying within range.
Intensive treatment of glycemia aiming at A1c <7% should be pursued as early as possible to prevent the development of microalbuminuria and macroalbuminuria.
The control of blood sugar levels can be achieved with a mixture of diet and oral antihyperglycemic agents and/or insulin. More on this later.
Hypertension (high blood pressure)
Hypertension is common in diabetic patients, even when the kidneys are not affected by the diabetes.
Treatment of hypertension dramatically reduces the risk of cardiovascular and microvascular events in patients with diabetes. Even a relatively small reduction in blood pressure can greatly reduce the risk of damage to the kidneys.. For this reason, blood pressure targets for patients with diabetes are lower than those for patients without diabetes. This can be achieved with a low sodium diet and the use of blood pressure lowering medications (antihypertensives) such as ACE inhibitors or ARB. ACE inhibitors have been shown to be beneficial for protecting the heart and kidneys in patients with type 1 and 2 diabetes.
Patients with diabetes have lower target lipid (cholesterol levels). If you have heart disease and kidney disease this level is even lower.
There is some evidence that lipid reduction with medications such as statins might preserve kidney function in diabetic patients.
Some studies show the benefits of statins in patients with diabetes, independent of their cholesterol level. Others show a marked reduction of cardiovascular events in patients with diabetes and at least one additional risk factor for coronary artery disease. These results suggest that all diabetic patients should be taking statins, independent of their cholesterol levels.
Tobacco cessation interventions have a positive impact on the cardiovascular and overall health of diabetic patients and can help delay the appearance of microalbuminuria and kidney damage.
Treatment of diabetic patients with micro- and macroalbuminuria
The main goal of treatment of diabetic patients with microalbuminuria is to prevent the progression from micro- to macroalbuminuria. In patients with macroalbuminuria, the main goal is to stop or delay the decline of renal function, and the occurrence of cardiovascular events.
The treatment principles are the same as those adopted for the prevention of diabetic nephropathy, although in this case multiple and more intensive strategies must be used. The strategies and goals are described in this table:
ACE inhibitor and/or ARB and low protein diet
(0.6 - 0.8 g per weight Kg per day)
Reduction of albuminuria or reverion to normoalbuminuria,
Reduce proteinuria as low as possible or < 0.5 g/24h and
reduce GFR < 2 ml per min per year
|Antihypertensive agents||Maintain blood pressure levels below 130/80 or 125/75 mmHg|
|Strict glycemic control||A1c < 7%|
|Statins||Decrease LDL cholesterol below 100 mg/dl|
|Acetyl salicylic acid||Prevent thrombosis|
|Stop smoking||Stop and prevent atherosclerosis|
No filter results
Intensive blood glucose control
The effect of strict glycemic control on the progression from micro- to macroalbuminuria and on the rate of renal function decline in macroalbuminuric patients is still controversial. Although the effects of strict glycemic control on the progression of diabetic nephropathy are not firmly established, it should be pursued in all these patients.
Different oral antihyperglycemic agents can help control the blood sugar levels and can also be helpful in protecting the kidneys of diabetic patients. Ask your doctor to see which one would be best for you.
In patients who develop diabetic nephropathy oral antihyperglycemic medication may not be sufficiently effective as the pancreas may only be producing very low and insufficient levels of insulin resulting from the long duration of diabetes. Thus, most type 2 diabetic patients with diabetic nephropathy should be treated with insulin.
Intensive blood pressure treatment and renin-angiotensin system blockade
In microalbuminuric type 1 and type 2 diabetic patients, numerous studies have demonstrated that treatment of hypertension, irrespective of the agent used, produced a beneficial effect on albuminuria.
The use of ACE inhibitors and ARBs to block the renin-angiotensin system (RAS) confers an additional benefit on renal function. This renoprotective effect is independent of blood pressure reduction. These drugs also decrease the rate of progression from microalbuminuria to more advanced stages of diabetic nephropathy.
It is more important to reach the blood pressure goals than to use a particular drug.
Regardless of the strategy chosen to reach the blood pressure goal, three to four antihypertensive agents are usually necessary. However, due to the known protective effect of ACE inhibitors and ARBs on the kidney, treatment should start with either of these agents. ARBs and ACE inhibitors can be combined if there is no reduction in albuminuria or if blood pressure target levels are not reached, even before maximizing the dose of each agent alone. Additional agents such as diuretics, beta blockers or calcium channel blockers should be added as needed and on a case by case basis.
Replacing red meat with chicken in the usual diet reduced urinary albumin excretion by 46% and reduced total cholesterol, LDL cholesterol, and apolipoprotein B in microalbuminuric patients with type 2 diabetes in a 4-week study. This was probably related to the lower amount of saturated fat and the higher proportion of polyunsaturated fatty acids found in chicken meat than in red meat.
A diet low in protein, low in sodium, low in carbohydrates, low in saturated but high in polyunsaturated fatty acids and rich in fiber can have a great impact in slowing DKD progression in diabetic patients with micro- or macroalbuminuria.
1. Radica Z. Alicic, Michele T. Rooney, Katherine R. Tuttle. CJASN Dec 2017, 12 (12) 2032-2045; DOI: 10.2215/CJN.11491116.
2. KDOQI. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis 2007; 49:S12.
3. Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Jorge L. Gross, Mirela J. de Azevedo, Sandra P. Silveiro, Luís Henrique Canani, Maria Luiza Caramori, Themis Zelmanovitz. Diabetes Care Jan 2005, 28 (1) 164-176; DOI: 10.2337/diacare.28.1.164.
4. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993.
5. UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317:703–713, 1998.
6. Fried LF, Orchard TJ, Kasiske BL: Effect of lipid reduction on the progression of renal disease: a meta-analysis. Kidney Int 59:260–269, 2001.
7. Mogensen CE: Microalbuminuria and hypertension with focus on type 1 and type 2 diabetes. J Intern Med 254:45–66, 2003.
8. The ACE Inhibitors in Diabetic Nephropathy Trialist Group: Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data. Ann Intern Med 134:370–379, 2001.
9. American Diabetes Association: Nephropathy in diabetes (Position Statement). Diabetes Care 27 (Suppl.1):S79–S83, 2004.
You might also like