Diabetic Kidney Disease: Diagnosis, Treatment, and Prevention

 

Am Fam Physician. 2019 Jun 15;99(12):751-759.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/diabetic-nephropathy/.

Author disclosure: No relevant financial affiliations.

Globally, approximately 20% of the 400 million individuals with diabetes mellitus have diabetic kidney disease (DKD). DKD is associated with higher cardiovascular and all-cause morbidity and mortality, so timely diagnosis and treatment are critical. Screening for early DKD is best done with annual spot urine albumin/creatinine ratio testing, and diagnosis is confirmed by repeated elevation in urinary albumin excretion. Treatment includes management of hyperglycemia, hypertension, hyperlipidemia, and cessation of tobacco use. Multiple antihyperglycemic medications, including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and dipeptidyl-peptidase-4 inhibitors, may help prevent DKD by lowering blood glucose levels and through intrinsic renal protection. Blood pressure should be monitored at every clinical visit and maintained at less than 140/90 mm Hg to prevent microvascular changes. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prevent progression of DKD and may decrease albuminuria. Statin therapy should be considered for all patients with DKD, and tobacco cessation reduces the risk of DKD. Given the complexity of the disease and the risk of poor outcomes, patients who progress to stage 3 DKD or beyond may benefit from referral to nephrology subspecialists.

Globally, more than 400 million people have diabetes mellitus and almost 600 million may be affected by 2035.1 In the United States, approximately 12% of the population has diabetes, and up to 25% of these individuals may be undiagnosed.2 The disease affects patients across all age groups, sexes, racial or ethnic groups, education levels, and income levels.2 Diabetic kidney disease (DKD) affects about 20% of patients with diabetes.3 DKD is associated with increased risks of morbidity and mortality and is the leading cause of end-stage renal disease (ESRD) in the United States.4,5

Prevention of diabetes in the general population is the most effective means of minimizing the impact of DKD; understanding risk factors for DKD development can help with early identification and intervention. Effectively using screening guidelines, treatment strategies, and subspecialty referral can help prevent progression of DKD. The role of primary care physicians in the management of patients with DKD secondary to type 2 diabetes is reviewed.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Individuals with type 2 diabetes mellitus should be screened for albuminuria at the time of diagnosis and annually thereafter.

C

9

Consistent clinical guideline

In adults with diabetes, metformin should be used as first-line therapy for glucose management because it is associated with A1C reduction, decreased risk of renal failure, and decreased mortality.

B

26, 31

Consensus clinical guideline based on large meta-analysis and systematic review

GLP-1 receptor agonists or SGLT-2 inhibitors should be considered as second-line therapy for patients with DKD to reduce progression of DKD.

B

1924, 27, 28, 31

Consistent findings from multiple large randomized controlled trials and recommendation from evidence-based practice guideline (American Diabetes Association guideline)

Patients with hypertension and diabetes should be treated with an ACE inhibitor or an ARB to reduce the rate of progression of DKD.

A

3739, 43

Multiple large randomized controlled trials

Patients with DKD should eat a protein-restricted diet (0.8 g per kg per day).

C

48, 49

Large meta-analysis

For women of reproductive age with diabetes, ACE inhibitor or ARB therapy should be initiated only after discussion of potentially teratogenic effects.

C

51

Expert-based clinical guideline


ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; DKD = diabetic kidney disease; GLP-1 = glucagon-like peptide-1; SGLT-2 = sodium-glucose cotransporter-2.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Individuals with type 2 diabetes mellitus should be screened for albuminuria at the time of diagnosis and annually thereafter.

C

9

Consistent clinical guideline

In adults with diabetes, metformin should be used as first-line therapy for glucose management because it is associated with A1C reduction, decreased risk of renal failure, and decreased mortality.

B

26, 31

Consensus clinical guideline based on large meta-analysis and systematic review

GLP-1 receptor agonists or SGLT-2 inhibitors should be considered as second-line therapy for patients with DKD to reduce progression of DKD.

B

1924, 27, 28, 31

Consistent

The Authors

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KATHRYN MCGRATH, MD, is a clinical assistant professor in the Department of Family and Community Medicine at Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pa....

RINA EDI, MD, is an assistant clinical professor in the Department of Family Medicine and Public Health at the University of California, San Diego.

Address correspondence to Kathryn McGrath, MD, 1015 Walnut St., 401 Curtis Bldg., Philadelphia, PA 19107 (e-mail: kathryn.mcgrath@jefferson.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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