Diabetic nephropathy medical therapy

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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

Medical treatment in diabetic nephropathy is aimed at slowing the progression of albuminuria. Interventions include

  • Improved glycemic control
  • Strict control of blood pressure
  • Treatment of dyslipidemia
  • Angtiotensin converting enzyme inhibitor (ACEI)
    • Preffered regimen no1. Enalapril: 2.5-5 mg once or twice daily, PO, increased up to 40 mg/day every 1-2 weeks in 2.5 mg intervals.
    • IV : 1.25 mg/dose every 6 hours
    • Preffered regimen no 2: Lisinopril: PO, Initial 10 mg daily (no diuretic) or 5 mg daily (if on diuretic). dose range: 10-40 mg daily.
  • Angiotensin receptor blocker (ARBs).[1][2]
    • Preffered regimen :Losartan PO 50 mg once daily, dose can be increased to 100 mg once daily based on blood pressure response.

Lifestyle Modifications

The management of diabetic nephropathy depends a lot on lifestyle and dietary modifications.These include:[3]

Glycemic Control

Certain anti-diabetic drugs have additional benefits in addition to lowering blood glucose levels. These include:[5]

Blood Pressure Control

Blood pressure in diabetic patients with nephropathy is aimed at levels of less than 130/80.[3][9][10]

Lipid Therapy

Dialysis

  • Dialysis may be necessary once end-stage renal disease develops.

References

  1. 1.0 1.1 Kasper, Dennis (2015). Harrison's Principles of Internal Medicine. New York, New York: McGraw-Hill. ISBN 0071802150.
  2. 2.0 2.1 2.2 2.3 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.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 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.
  4. Nathan DM (1993). "Long-term complications of diabetes mellitus". N. Engl. J. Med. 328 (23): 1676–85. doi:10.1056/NEJM199306103282306. PMID 8487827.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 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)
  6. Mori H, Okada Y, Arao T, Tanaka Y (2014). "Sitagliptin improves albuminuria in patients with type 2 diabetes mellitus". J Diabetes Investig. 5 (3): 313–9. doi:10.1111/jdi.12142. PMC 4020336. PMID 24843780.
  7. Cherney DZ, Perkins BA, Soleymanlou N, Maione M, Lai V, Lee A, Fagan NM, Woerle HJ, Johansen OE, Broedl UC, von Eynatten M (2014). "Renal hemodynamic effect of sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetes mellitus". Circulation. 129 (5): 587–97. doi:10.1161/CIRCULATIONAHA.113.005081. PMID 24334175.
  8. Anders, Hans‐Joachim; Davis, John M.; Thurau, Klaus (2016). "Nephron Protection in Diabetic Kidney Disease". The New England Journal of Medicine. 375 (21): 2096–2098. doi:10.1056/NEJMcibr1608564.
  9. "American Diabetes Association Clinical Practice Recommendations 2001". Diabetes Care. 24 Suppl 1: S1–133. 2001. PMID 11403001.
  10. 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.
  11. "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.
  12. 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.




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