Diabetes is the leading cause of end-stage renal disease (ESRD). Intensive glucose control and blood pressure reduction have been shown to reduce onset and progression of nephropathy in type 1 and type 2 diabetes. 1, 3 While blood pressure control is important for all people with diabetes, it is particularly imperative to achieve blood pressure control in people with diabetic nephropathy, both to prevent progression of nephropathy and because nephropathy is a risk factor for cardiovascular disease (CVD). Early recognition of kidney damage in people with diabetes allows for preventive measures to slow or prevent progressive loss of kidney function.
Use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to lower systolic blood pressure in people with diabetes and albuminuria slows the rise in levels of albuminuria and the decline in glomerular filtration rate (GFR). ACE inhibitors also reduce major CVD outcomes in people with type 2 diabetes. 4
Persistent albuminuria is an early marker of diabetic kidney disease and is useful for monitoring progression and prognosis. Urine albumin excretion exceeding what is considered normal (< 30 mg/day), even when below what is detected by dipstick (equivalent to 300 mg/day), is an early marker of diabetic nephropathy and a risk factor for CVD. Albuminuria increases with diabetes progression. High levels of albuminuria are associated with rapid progression. However, decreased GFR can occur in the absence of albuminuria in people with diabetes. 4
- Annually assess urine albumin excretion in adults and children with type 1 diabetes with diabetes duration of more than 5 years and in adults and children with type 2 diabetes starting at diagnosis. Use the albumin-to-creatinine ratio in a random spot urine collection to assess urine albumin excretion. Results are reported as albumin in mg/g creatinine and are equivalent to albumin excretion in mg/day.
- Annually measure serum creatinine in all adults with diabetes regardless of the degree of urine albumin excretion. Use the serum creatinine to estimate GFR.
- Hyperglycemia and hypertension are major risk factors for the onset and progression of nephropathy. Multiple drugs are often required to control blood pressure. Therapy should be individualized based on risks and benefits. For more information about blood glucose and blood pressure control, refer to Principles 6 and 7.
- Use an ACE inhibitor or an ARB to manage nonpregnant people with hypertension and diabetes. Patients without hypertension and with urine albumin-to-creatinine ratio (UACR) higher than 300 mg/g should also receive an ACE inhibitor or ARB. Evidence for treatment of nonhypertensive people with lower levels of albuminuria (30–300 mg/g creatinine) is less well supported. Do not use these medications in pregnant women or women considering pregnancy.
- Refer people to a registered dietitian/registered dietitian nutritionist specializing in kidney disease to help moderate intake of dietary sodium, phosphorus, potassium, and protein as necessary.
- Screen for anemia, malnutrition (e.g., low serum albumin), and mineral and bone disease (potassium, bicarbonate, calcium, phosphorus, and vitamin D deficiency) when the estimated GFR is less than 60 mL per minute per 1.73 m 2.
- Consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease (active urine sediment, heavy proteinuria, absence of retinopathy, or rapid decline in GFR), difficult management issues, or advanced kidney disease.
- Educate people with diabetes about the progressive nature of kidney disease, the renal preservation benefits of optimal management of blood pressure and blood glucose, the importance of a low-sodium diet, and the potential need for renal replacement therapy.
Resources for nephropathy