Diabetic nephropathy screening -
The goal of treatment is to prevent the progression from micro- to macroalbuminuria, the decline of renal function in patients with macroalbuminuria, and the occurrence of cardiovascular events. The treatment principles are the same as those adopted for the prevention of diabetic nephropathy, although in this case multiple and more intensive strategies must be used.
The strategies and goals are described in Table 2. The effect of strict glycemic control on the progression from micro- to macroalbuminuria and on the rate of renal function decline in macroalbuminuric patients is still controversial.
In the DCCT study, intensified glycemic control did not decrease the rate of progression to macroalbuminuria in patients with type 1 diabetes who were microalbuminuric at the beginning of the study 95 , The Microalbuminuria Collaborative Study Group reported similar findings However, these studies , were underpowered to detect an effect of intensified glycemic control on the progression from micro- to macroalbuminuria.
Moreover, improvement of glycemic control, especially if associated with lower blood pressure levels, reduced the renal function decline in proteinuric type 1 diabetic patients In patients with type 2 diabetes, very few studies analyzed the role of blood glucose control on the progression of diabetic nephropathy.
In the Kumamoto Study, a reduction in the conversion from micro- to macroalbuminuria was observed with intensive treatment Although the effects of strict glycemic control on the progression of diabetic nephropathy are not firmly established, it should be pursued in all these patients.
Some oral antihyperglycemic agents seem to be especially useful. Rosiglitazone, as compared with glyburide, has been shown to decrease UAE in patients with type 2 diabetes. This suggests a beneficial effect in the prevention of renal complications of type 2 diabetes Also, the use of antihyperglycemic agents in proteinuric type 2 diabetic patients should take renal function into account.
Sulfonylureas and their metabolites, except glimepiride, are eliminated via renal excretion and should not be used in patients with decreased renal function Repaglinide and nateglinide have a short duration of action, are excreted independently of renal function, and have a safety profile in patients with renal impairment.
However, at this point, sulfonylureas and insulin secretagogues are usually not very effective due to the low endogenous production of insulin resulting from the long duration of diabetes.
Thus, most type 2 diabetic patients with diabetic nephropathy should be treated with insulin. In microalbuminuric type 1 and type 2 diabetic patients, numerous studies have demonstrated that treatment of hypertension, irrespective of the agent used, produced a beneficial effect on albuminuria Renin-angiotensin system RAS blockade with ACE inhibitors or ARBs confers an additional benefit on renal function.
This renoprotective effect is independent of blood pressure reduction , and may be related to decreased intraglomerular pressure and passage of proteins into the proximal tubule These drugs decrease UAE and the rate of progression from microalbuminuria to more advanced stages of diabetic nephropathy.
ARBs were also effective in reducing the development of macroalbuminuria in microalbuminuric type 2 diabetic patients. It is also interesting to note that UAE was still reduced 1 month after the withdrawal of irbesartan These data reinforce the idea that the antiproteinuric effect of ARBs is blood pressure independent.
Although there is no long-term study comparing the effects of ACE inhibitors and ARBs on the progression from microalbuminuria to overt diabetic nephropathy, both agents led to a similar reduction in albuminuria in a week study and a 1-year study Therefore, the use of either ACE inhibitors or ARBs is recommended as a first-line therapy for type 1 and type 2 diabetic patients with microalbuminuria, even if they are normotensive In proteinuric patients, Mogensen was the first to demonstrate, almost 30 years ago, that treatment of hypertension reduced albuminuria and the rate of GFR decline in type 1 diabetic patients.
Subsequently, other studies have clearly demonstrated that aggressive treatment of hypertension has a strong beneficial effect in reducing GFR decline in proteinuric type 1 diabetic patients This reduction in GFR decline was predicted by reduction in albuminuria According to the MDRD Modification of Diet in Renal Disease trial, the lower the blood pressure, the greater the preservation of renal function in nondiabetic patients Although this study included mainly nondiabetic patients, this goal also has been recommended for proteinuric diabetic patients Addition of ACE inhibitors in proteinuric type 1 diabetic patients or ARBs in macroalbuminuric type 2 diabetic patients , decreased proteinuria and renal function decline.
Although there was no difference in the cardiovascular event rate, a significantly lower incidence of congestive heart failure was observed among patients receiving ARBs The antiproteinuric effect of ARBs has certain characteristics.
It occurs early within 7 days after treatment is started and persists stable thereafter , and it is independent of blood pressure reduction and has a dose-response effect beyond the doses needed to control blood pressure This raise in creatinine is associated with long-term preservation of renal function, and therefore ACE inhibitors should not be stopped Greater increases should raise the suspicion of renal-artery stenosis.
Inhibition of the RAS, especially with ACE inhibitors, might raise serum potassium levels, particularly in patients with renal insufficiency For these reasons, albuminuria, serum creatinine, and potassium should be checked monthly during the first 2—3 months after starting treatment with ACE inhibitors or ARBs.
Recently, Mogensen et al. ACE inhibitors and ARBs interrupt the RAS at different levels, and the combination of these classes of drugs may have an additive effect on renoprotection.
Other studies have also demonstrated that the combination of ACE inhibitors and ARBs had a synergistic effect in blood pressure and UAE reduction in patients with type 1 and type 2 diabetes with diabetic nephropathy.
RAS dual blockade is more effective in reducing UAE than maximal recommended doses of ACE inhibitors alone Even though no long-term trials analyzing the benefit of RAS dual blockade in diabetic nephropathy are available, in nondiabetic proteinuric patients the COOPERATE Combination Treatment of Angiotensin-II Receptor Blocker and Angiotensin-Converting-Enzyme Inhibitor in Nondiabetic Renal Disease trial has shown that dual therapy was superior to monotherapy at its maximal doses in retarding the progression of renal disease in a 3-year follow-up The combination of spironolactone, an aldosterone antagonist, with an ACE inhibitor was also more effective in reducing UAE and blood pressure in micro- and macroalbuminuric type 2 diabetic patients than the ACE inhibitor alone A detailed discussion of the agents used to treat hypertension in patients with diabetic nephropathy is beyond the scope of this article, and recent guidelines , and reviews on this subject are available , , Therefore, only general guidelines will be discussed here, taking into account the special characteristics of these patients.
It is more important to reach the blood pressure goals than to use a particular agent, since most patients will require several agents. However, due to the known renoprotective effect of ACE inhibitors and ARBs, treatment should start with either of these agents.
Patients with systolic blood pressure 20 mmHg or diastolic blood pressure 10 mmHg above the goal should start treatment with two agents.
An ACE inhibitor or ARB and a low-dose thiazide diuretic ARBs and ACE inhibitors can be combined if there is no reduction in albuminuria or if blood pressure target levels are not reached, even before maximizing the dose of each agent.
Additional agents should be added as needed. Calcium channel blockers have an additional effect on reducing blood pressure levels. These agents should only be used in combination with an ACE inhibitor and should not be used in patients with a recent coronary event.
Possibly, a metabolic neutral compound, carvedilol, should be used. The combination of β-blockers and nondihydropyridine calcium channel blockers should be used with caution, since both agents have negative chronotropic effects.
Blood pressure treatment could be assessed by h ambulatory monitoring in the following situations: in patients with treatment-resistant hypertension, when there is a suspicion of white coat hypertension, or to detect drug-induced or autonomic neuropathy—related hypotensive episodes This was probably related to the lower amount of saturated fat and the higher proportion of polyunsaturated fatty acids found in chicken meat than in red meat.
The beneficial effect of polyunsaturated fatty acids on endothelial function could also reduce UAE. A normal protein diet with chicken as the only source of meat may represent an additive strategy for the treatment of microalbuminuric type 2 diabetic patients.
However, long-term studies are necessary. According to a meta-analysis of five studies including a total of patients, dietary protein restriction slowed the progression of diabetic nephropathy in patients with type 1 diabetes. More recently, a 4-year randomized controlled trial in 82 patients with type 1 diabetes with progressive diabetic nephropathy showed that a moderately low—protein diet 0.
The effect of lipid reduction by antilipemic agents on progression of diabetic nephropathy is still unknown. So far, there have been no large trials analyzing whether the treatment of dyslipidemia could prevent the development of diabetic nephropathy or the decline of renal function.
However, there is some evidence that lipid reduction by antilipemic agents might preserve GFR and decrease proteinuria in diabetic patients Moreover, the results of the recently presented CARDS Collaborative Atorvastatin Diabetes Study , which showed a marked reduction of cardiovascular events in patients with diabetes and at least one additional risk factor for coronary artery disease, suggest that all diabetic patients should be taking statins www.
Furthermore, anemia has been considered a risk factor for progression of renal disease and retinopathy Low-dose aspirin has been recommended for primary and secondary prevention of cardiovascular events in adults with diabetes.
This therapy did not have a negative impact on renal function UAE or GFR in type 1 and type 2 diabetic patients with micro- or macroalbuminuria , Although this study was underpowered to analyze the effect on the development of cardiovascular events, these data raise the issue that diabetic patients could be less responsive to aspirin therapy aspirin resistance.
This phenomenon was associated with higher levels of A1c, lower concentration of HDL cholesterol, and higher concentration of total cholesterol Patients with microalbuminuria frequently have other cardiovascular risk factors, such as hypertension and dyslipidemia.
In the Steno-2 study, multifactorial intervention was compared with conventional treatment in microalbuminuric type 2 diabetic patients The multifactorial intervention consisted of a stepwise implementation of lifestyle changes and pharmacological therapy, including a low-fat diet, a three to five times a week light-to-moderate exercise program, a smoking cessation program, and prescription of ACE inhibitors or ARBs and aspirin.
The measures described above might not be effective in some patients with diabetes, and novel therapeutic strategies are warranted. High doses of thiamine and its derivate benfotiamine have been shown to retard the development of microalbuminuria in experimental diabetic nephropathy, probably due to decreased activation of protein kinase C, decreased protein glycation, and oxidative stress Treatment with ALT, a cross-link breaker of the advanced glycation end products, has been shown to result in a significant reduction in UAE, blood pressure, and renal lesions in experimental diabetes Treatment with a protein kinase C β inhibitor ruboxistaurin normalized GFR, decreased albumin excretion rate, and ameliorated glomerular lesions in diabetic rodents In a rat model of diabetes-induced glomerulosclerosis, administration of a modified heparin glycosaminoglycan prevented albuminuria, glomerular, and tubular matrix accumulation and transforming growth factor β1 mRNA overexpression Very few studies have been conducted in humans.
Sulodexide, a glycosaminoglycan, significantly reduced albuminuria in micro- or macroalbuminuric type 1 and type 2 diabetic patients Pimagedine, a second-generation inhibitor of advanced glycation end products, reduced urinary protein excretion and the decline in GFR in proteinuric type 1 diabetic patients in a randomized, placebo-controlled study In the last few years, we have witnessed enormous progress in the understanding of the risk factors and mechanisms of diabetic nephropathy, the stages of renal involvement in diabetes, and the treatment strategies to prevent or interrupt the progression of diabetic nephropathy.
Treatment of hypertension is a priority. Attention to these procedures will also ensure the reduction of cardiovascular mortality.
In a 5-year prospective study, Barnett et al. Diabetic nephropathy stages: cutoff values of urine albumin for diagnosis and main clinical characteristics.
This study was partially supported by Projeto de Núcleos de Excelência do Ministério de Ciência e Tecnologia, Conselho Nacional de Desenvolvimento Científico e Tecnológico CNPq , and Hospital de Clínicas de Porto Alegre. A table elsewhere in this issue shows conventional and Système International SI units and conversion factors for many substances.
Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Diabetes Care. Advanced Search. User Tools Dropdown. Sign In.
Skip Nav Destination Close navigation menu Article navigation. Volume 28, Issue 1. Previous Article Next Article. STAGES, CLINICAL FEATURES, AND CLINICAL COURSE. SCREENING AND DIAGNOSIS. Article Information. Article Navigation. Diabetic Nephropathy: Diagnosis, Prevention, and Treatment Jorge L.
Gross, MD ; Jorge L. Gross, MD. From the Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. This Site. Google Scholar. Mirela J. de Azevedo, MD ; Mirela J. de Azevedo, MD. Sandra P. Silveiro, MD ; Sandra P. Silveiro, MD.
Luís Henrique Canani, MD ; Luís Henrique Canani, MD. Maria Luiza Caramori, MD ; Maria Luiza Caramori, MD. Themis Zelmanovitz, MD Themis Zelmanovitz, MD. Address correspondence and reprint requests to Jorge L.
Gross, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos , Prédio 12, 4° andar, , Porto Alegre, RS, Brazil. E-mail: jorgegross terra. Diabetes Care ;28 1 — Article history Received:. Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest.
Table 1— Diabetic nephropathy stages: cutoff values of urine albumin for diagnosis and main clinical characteristics. Albuminuria cutoff values ref.
Clinical characteristics ref. View Large. Table 2— Strategies and goals for reno- and cardioprotection in patients with diabetic nephropathy. Arch Intern Med. N Engl J Med. Acta Endocrinol Copenh.
Kidney Int. Diabetes Care. Diabet Med. J Diabetes Complications. Am J Kidney Dis. Clin Chem. Kidney Int Suppl. Braz J Med Biol Res. Ann Intern Med. Scand J Clin Lab Invest. Am J Med. Nephrol Dial Transplant. J Am Soc Nephrol. When the kidneys no longer work, dialysis or an organ transplant is needed to stay alive.
Diabetes nephropathy is also difficult to detect. Common symptoms, such as nausea, changes in urination, swelling limbs, or muscle aches, may be easily dismissed or confused with other conditions.
Regular screenings are the most effective way to monitor changes in kidney health. They can make early detection possible so treatment and lifestyle changes can slow or stop the progression of diabetic nephropathy.
Regularly screening your kidney health is a part of actively managing diabetes. Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available.
People with kidney disease and diabetes should monitor their intake of certain nutrients. Here are 5 foods to avoid with kidney disease and diabetes. Nephropathy is one of the more serious, potentially life-threatening complications of diabetes.
But there are steps you can take to lower your risk of…. Tips for managing diabetes and depression to avoid developing kidney disease. One of the most common electrolyte imbalances experienced by people with kidney disease, which can lead to muscle weakness, pain, or even paralysis….
A low GFR may be an indicator of kidney…. High protein levels in the urine are known as proteinuria. Discover 11….
A urine protein test measures the amount of protein in urine. This test can be used to diagnose a kidney condition or see if a treatment is working.
Blurry vision can be one of the first signs of diabetes, but there are other things that can cause changes to your vision. A Quiz for Teens Are You a Workaholic? How Well Do You Sleep? Health Conditions Discover Plan Connect.
How to Screen for Diabetes-Related Nephropathy. Medically reviewed by Kelly Wood, MD — By Corinna Cornejo on February 13, Urine protein test. Estimated glomerular filtration rate eGFR. Imaging tests. Kidney biopsy. Learn more about diabetic nephropathy You can lower your risk of diabetes-related kidney disease by regularly monitoring and managing your glucose levels and kidney health, along with getting annual health screens.
Was this helpful? How often should you get screened for diabetic kidney disease? Is there a test that diagnoses diabetes kidney disease?
Why is screening for diabetic nephropathy important? How we reviewed this article: Sources. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations.
We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy. Feb 13, Written By Corinna Cornejo. Share this article. Read this next. Kidney Disease in Diabetes: How to Lower Your Risk of Nephropathy.
Medically reviewed by Marina Basina, M. What to Know About the Connection Between Diabetes, Depression, and Kidney Disease. Medically reviewed by Tiffany Taft, PsyD.
Diabetic nephropathy Diabehic a Fasting Diet for Beginners complication of type 1 diabetes and type 2 Fasting Diet for Beginners. Bephropathy also called nephropatny Fasting Diet for Beginners disease. In the Diaberic States, about 1 in 3 people living Daibetic diabetes Regular check-ups diabetic nephropathy. Diabetic nephropathy affects the kidneys' usual work of removing waste products and extra fluid from the body. The best way to prevent or delay diabetic nephropathy is by living a healthy lifestyle and keeping diabetes and high blood pressure managed. Over years, diabetic nephropathy slowly damages the kidneys' filtering system. Early treatment may prevent this condition or slow it and lower the chance of complications. The Diabeitc manifestations, evaluation, and diagnosis of diabetic Fasting Diet for Beginners disease scdeening reviewed in this topic. Other topics discuss the following issues:. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you.
ist mit der vorhergehenden Mitteilung absolut einverstanden
Es ist die einfach ausgezeichnete Idee
Sehr, sehr