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How to protect the kidney in diabetic patients: with special reference to IDDM
1Medical Department M, Diabetes & Endocrinology, Aarhus Kommunehospital, Aarhus University Hospital, Denmark.
Abstract:
During the development to overt nephropathy, diabetic patients go through several characteristic stages of renal disease, moving from normo- to micro- to macroalbuminuria. Microalbuminuria is defined as a urinary albumin excretion between 20 and 200 microg/min; values <20 microg/min are designated as normoalbuminuria, and values >200 microg/min are designated as macroalbuminuria. Only with macroalbuminuria does the glomerular filtration rate (GFR) fall consistently. The decisive intermediary endpoints are postponement or prevention of micro/macroalbuminuria and reduction or prevention of the fall in GFR (stronger endpoint), with postponement of end-stage renal disease as a final endpoint. Good metabolic control can prevent or postpone the development of microalbuminuria, the earliest sign of diabetic renal disease. The ideal realistic therapeutic window may be an HbA1c value between 7 and 8.5% (mean reference value 5.5%). Thus, efforts should aimed at implementing the best possible control before the onset of microalbuminuria, with the other important aim of minimizing hypoglycemic side effects. In patients with microalbuminuria, blood pressure gradually increases, and early antihypertensive treatment becomes crucial. Good glycemic control (with the same glycemic goal as above) may be difficult to achieve in some of these patients, but it is still important. With overt nephropathy, defined as clinical proteinuria, a relentless decline in GFR is inflicted, unless patients are carefully treated with antihypertensive agents, often in combination therapy. Good metabolic control is still strongly warranted because patients with high HbA1c progress much more rapidly. The natural history of the rate of fall in GFR may be reduced from 12 to 3 ml x min(-1) x year(-1), but genetic factors may be involved; the ACE-genotype DD seems to progress more rapidly during treatment. Protein restriction is also of some interest. Early screening is recommended in all guidelines, with emphasis on testing for albuminuria, including microalbuminuria, along with careful control of glycemia and blood pressure.
Insights
Diabetic kidney disease progresses through stages of albuminuria. Early intervention with good glycemic control (HbA1c 7-8.5%) and blood pressure management can prevent or delay microalbuminuria and end-stage renal disease.
Area of Science:
- Nephrology
- Diabetology
- Endocrinology
Background:
- Diabetic nephropathy progresses through stages: normoalbuminuria, microalbuminuria (20-200 µg/min), and macroalbuminuria (>200 µg/min).
- Glomerular filtration rate (GFR) decline is minimal until macroalbuminuria, after which it falls consistently.
- Key endpoints include preventing micro/macroalbuminuria, slowing GFR decline, and delaying end-stage renal disease.
Purpose of the Study:
- To outline the stages of diabetic nephropathy and identify key therapeutic endpoints.
- To emphasize the role of metabolic and blood pressure control in managing diabetic kidney disease.
- To highlight the importance of early screening for albuminuria.
Main Methods:
- Review of characteristic stages of renal disease in diabetic patients.
- Definition of albuminuria levels (normo-, micro-, macroalbuminuria) and their relation to GFR.
- Discussion of therapeutic strategies including glycemic control, antihypertensive treatment, and protein restriction.
Main Results:
- Good metabolic control (HbA1c 7-8.5%) can prevent or postpone microalbuminuria, the earliest sign of diabetic renal disease.
- Antihypertensive treatment is crucial in patients with microalbuminuria and overt nephropathy to slow GFR decline.
- ACE-genotype DD may be associated with more rapid GFR decline during treatment.
Conclusions:
- Early screening for albuminuria and meticulous control of glycemia and blood pressure are essential for managing diabetic nephropathy.
- Implementing optimal metabolic control before microalbuminuria onset is critical, balancing efficacy with minimizing hypoglycemia.
- Aggressive antihypertensive therapy, potentially combined with protein restriction, is necessary for patients with overt nephropathy to preserve GFR.