The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is ACE inhibitor drugs, which usually reduces proteinuria levels and slows the progression of diabetic nephropathy. Several effects of the ACEIs that may contribute to renal protection have been related to the association of rise in Kinins which is also responsible for some of the side effects associated with ACEIs therapy such as dry cough.
The renal protection effect is related to the antihypertensive effects in normal and hypertensive patients, renal vasodilatation resulting in increased renal blood flow and dilatation of the efferent arterioles. Many studies have shown that related drugs, angiotensin receptor blockers (ARBs), have a similar benefit. However, combination therapy, according to the ONTARGET study, is known to worsen major renal outcomes, such as increasing serum creatinine and causing a greater decline in estimated glomerular filtration rate (eGFR).
Blood-glucose levels should be closely monitored and controlled. This may slow the progression of the disorder, especially in the very early ("microalbuminuria") stages. Medications to manage
diabetes include oral
hypoglycemic agents and
insulin injections. As
kidney failure progresses, less insulin is excreted, so smaller doses may be needed to control glucose levels.
Diet may be modified to help control blood-sugar levels. Modification of protein intake can effect hemodynamic and nonhemodynamic injury.
High blood pressure should be aggressively treated with antihypertensive medications, in order to reduce the risks of kidney, eye, and blood vessel damage in the body. It is also very important to control lipid levels, maintain a healthy weight, and engage in regular physical activity.
Patients with diabetic nephropathy should avoid taking the following drugs:
- Contrast agents containing iodine
- Commonly used non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen, or COX-2 inhibitors like celecoxib, because they may injure the weakened kidney.
Urinary tract and other infections are common and can be treated with appropriate antibiotics.
Dialysis may be necessary once end-stage renal disease develops. At this stage, a kidney transplantation must be considered. Another option for type 1 diabetes patients is a combined kidney-pancreas transplant.
C-peptide, a by-product of insulin production, may provide new hope for patients suffering from diabetic nephropathy.
Currently, several compounds are in development for diabetic kidney disease. These include, but are not limited to, bardoxolone methyl, olmesartan medoxomil, sulodexide, and avosentan
Further Reading
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"Diabetic nephropathy"
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