Archive for February, 2009

Diabetic Nephropathy: Treatment

The most effective therapy of diabetic nephropathy is prevention (like diabetic retinopathy) by controlling hyperglycemia. As part of comprehensive diabetes management microalbuminuria should be detected as early as possible and effective therapy started. For detecting microalbuminuria annual urine analysis is done by ‘spot collection’ method. If a sample of urine is tested positive for microalbuminuria, repeat the test after 3-6 months and if tow tests are positive out of three, than treatment for diabetic nephropathy is started. Annual measurement of serum creatinine is also done to find out GFR (glomerular filtration rate) to find out renal function.

The following treatment modalities are used to slow down progression of microalbuminuria to macroalbuminoria:

  1. Control of blood glucose: If blood glucose level is controlled within normal limit the progression to retinopathy (from microalbuminuria to macroalbuminoria) is much less, both in type 1 and type 2 diabetes. But once macroalbuminoria is established it is not clear if control of blood sugar can slow down the progression of renal disease. If renal function is much less than normal insulin requirement is lees, because kidneys are the main site of degradation of insulin. Many oral hypoglycemic agents like metformin and sulfonylureas are contraindicated during renal insufficiency.   
  2. Control of blood pressure: High blood pressure is a common accompanying disease in diabetics of type1 and type2. Strict blood pressure control is required to prevent diabetic nephropathy in diabetics. Many studies have shown that control of blood pressure to <130/80 mm Hg can reduce diabetic retinopathy and decline in renal function. If microalbuminuria has already set in little lower blood pressure should be maintained (< 125/75 mm Hg).
  3. Administration of ACE (angitensin converting enzyme) inhibitors or ARBs (angitensin receptor blockers): ACE inhibitors or ARBs should be used to reduce progression of microalbuminuria to macroalbuminoria and decline in GFR. Most authors believe that bothe ACE inhibitiors and ARBs are equally efficacious in preventing retinopathy in diabetes by controlling blood pressure. ARBs are used as alternative if there is development of side effects with ACE inhibitors like cough, angioedema etc. The dose of ACE inhibitors is increased till microalbuminuria disappear or maximum dose is reached. If either groups can not be used than beta blockers, calcium channel blockers or diuretics are used though the benefit is not as good as the two groups (ACE inhibitors and ARBs). The best benefit is seen with these two groups only in case of diabetes.

ADA (American diabetic association) recommends slight reduction of protein intake for patients with microalbuminuria to 0.8 gm/kg per day and with macroalbuminoria to less than 0.08 gm/kg per day or no more than 10% of daily total calorie intake.

Expert nephrology consultation is required if GFR is less than 60 ml/min per 1.743 m2. If macroalbuminoria develops the chances of end stage renal disease is very high. Dialysis of diabetic patients can lead to more complications than a non diabetic patient and survival is also much less in them.  

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Posted by - February 11, 2009 at 1:51 am

Categories: Disease Treatment   Tags: ,