However, studies, Diabdtic ROADMAP Randomized Olmesartan Metabolism Boosting Supplements Diabetes Diabetic kidney disease Prevention Diabeitc, have shown that RAS blockade can prevent the development of microalbuminuria in T2DM. The exact time of the onset of T2DM is unclear in most patients. Many people with diabetes also develop high blood pressurewhich can also damage your kidneys. Rastogi A, Bhansali A.

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Diabetes and Kidney Disease

Diabetic kidney disease -

In a pooled analysis of these two trials, finerenone lowered the risk of kidney failure 3. The great majority of patients enrolled in these two trials were not simultaneously treated with an SGLT2 inhibitor, and the subgroup of patients who were was too small to determine with certainty whether or not finerenone provided additional benefit.

Another nonsteroidal MRA, esaxerenone, also reduces albuminuria in patients with DKD [ 69 ]. However, trials of esaxerenone report higher rates of hyperkalemia than those examining finerenone [ ], and the effects of esaxerenone on mortality and ESKD are unknown. However, the effect was predominantly due to a reduction in new-onset albuminuria.

Similarly, another GLP-1 receptor agonist dulaglutide slowed the rate of decline in eGFR and prevented worsening of albuminuria in trials of patients with type 2 diabetes with and without CKD [ 73,74 ]. Thus, if additional glucose-lowering therapy is required in a patient with DKD despite initial glucose-lowering therapy and an SGLT2 inhibitor, then we would prefer starting a GLP-1 receptor agonist.

GLP-1 receptor agonists also reduce the rates of cardiovascular disease [ 31 ]. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Microvascular outcomes' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects'.

By inhibiting dipeptidyl peptidase DPP 4, DPP-4 inhibitors prevent the deactivation of a variety of bioactive peptides, including GLP-1, thereby modestly increasing GLP-1 levels. However, unlike GLP-1 receptor agonists, DPP-4 inhibitors have not prevented the development or progression of kidney disease in patients with diabetes, nor do they have any cardiovascular benefits [ 75,76 ].

The use of DPP-4 inhibitors in patients with type 2 diabetes, including their safety and need for dose adjustments in the setting of CKD, is discussed separately.

See "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus". A large trial of more than individuals with type 2 diabetes treated with metformin monotherapy directly compared the kidney effects of the GLP-1 receptor agonist liraglutide with a DDP-4 inhibitor, insulin, and glimepiride [ 77 ].

There were no significant differences among the groups at five years in terms of eGFR decline or development of CKD in this low-risk group. The patients enrolled had normal kidney function and well controlled blood pressure at baseline, and the number of events was small.

This study does not support the use of expensive GLP-1 receptor agonists for kidney protection in patients at low risk. Therapies of limited use — Various other approaches have been studied as methods to slow the progression of DKD. However, there are insufficient data to advocate their use:.

Data are conflicting as to whether protein restriction can slow the progression of kidney disease [ ]. In addition, it is uncertain whether a low-protein diet is significantly additive to other measures aimed at preserving kidney function, such as ACE inhibition and aggressive control of blood pressure and blood glucose [ 78 ].

Other aspects of monitoring should be based upon the clinical situation. See "Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers". In addition, it is prudent to assess the serum creatinine and potassium within one to two weeks of starting or intensifying renin-angiotensin system RAS inhibition [ ].

Blood pressure should be assessed within one to two weeks of initiating or intensifying these agents. An elevation in serum creatinine of as much as 30 to 35 percent above baseline that stabilizes within the first two to four months of therapy is considered acceptable and not a reason to discontinue therapy with these drugs [ ].

Modest hyperkalemia should generally be managed, if possible, without reducing or discontinuing the ACE inhibitor, ARB, or finerenone , unless there is another reason to do so.

If discontinued for hyperkalemia, the ACE inhibitor or ARB should be resumed as soon as it is safe to do so. See "Treatment and prevention of hyperkalemia in adults", section on 'Patients who can have the serum potassium lowered slowly'.

Similarly, the serum creatinine, serum potassium, and blood pressure, plus the patient's volume status, should generally be ascertained within a few weeks of commencing a sodium-glucose cotransporter 2 SGLT2 inhibitor.

See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Hypotension'. Both RAS inhibition and SGLT2 inhibitors may increase the risk of symptomatic hypotension, and other antihypertensive therapies should be withdrawn first if possible before considering cessation of these evidence-based therapies.

Similarly, SGLT2 inhibitors may cause volume depletion, and withdrawal or reduction of thiazide or loop diuretics should be attempted before discontinuing the SGLT2 inhibitor.

See "Definition and staging of chronic kidney disease in adults", section on 'Referral to a specialist'. PROGNOSIS — A substantial proportion of people with diabetic kidney disease DKD will have progressive loss of kidney function and will develop end-stage kidney disease ESKD.

The strongest risk factor for risk of progression is the presence of increased albuminuria, while people with reduced estimated glomerular filtration rate eGFR or anemia are also at increased risk.

With available protective therapies, a dramatic stabilization of kidney function is likely to be achievable. See "Diabetic kidney disease: Manifestations, evaluation, and diagnosis", section on 'Natural history'. Of note, people with DKD are at particularly high risk of cardiovascular events, and most have a higher risk of death mostly cardiovascular than developing kidney failure.

Cardiovascular protective therapies are therefore also critical. See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Reducing the risk of macrovascular disease'. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Glomerular disease in adults" and "Society guideline links: Chronic kidney disease in adults" and "Society guideline links: Diabetic kidney disease". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.

The evidence supporting our recommendation is presented separately. See "Goal blood pressure in adults with hypertension", section on 'Patients with chronic kidney disease' and "Goal blood pressure in adults with hypertension", section on 'Patients with diabetes mellitus' and 'Blood pressure control' above.

However, glycemic targets in type 1 diabetes have not been well studied in patients with advanced chronic kidney disease CKD. The approach to target an A1C of 7 percent or less, if tolerated is similar in patients with type 2 diabetes, although fewer supportive data are available than for type 1 diabetes.

The evidence for these approaches is presented elsewhere. See "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetes mellitus" and 'Glycemic control' above.

See 'Other' above. However, while these drugs are more beneficial than other antihypertensive agents in patients with albuminuric DKD, they do not have clear advantages over calcium channel blockers or diuretics among those without albuminuria.

See 'Severely increased albuminuria: Treat with angiotensin inhibition' above. We also suggest use of an SGLT2 inhibitor in patients with DKD who have lower levels of urine albumin excretion Grade 2B. The SGLT2 inhibitor is typically added to the patient's existing glucose-lowering regimen since these drugs have weak glucose-lowering effects in patients with reduced kidney function.

See 'Type 2 diabetes: Treat with additional kidney-protective therapy' above. SGLT2 inhibitors increase the risk of genital infections by two- to fourfold primarily vulvovaginal candidiasis and have been associated with Fournier's gangrene in rare cases.

SGLT2 inhibitors are not appropriate for use in patients with type 1 diabetes and kidney disease. See 'Monitoring during therapy' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you.

Select the option that best describes you. View Topic. Font Size Small Normal Large. Treatment of diabetic kidney disease. Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share.

View in. Language Chinese English. Authors: Vlado Perkovic, MBBS, PhD Sunil V Badve, MD, PhD George L Bakris, MD Section Editors: Richard J Glassock, MD, MACP David M Nathan, MD Deputy Editor: John P Forman, MD, MSc Contributor Disclosures.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Jul 17, aspx Accessed on March 05, Jamerson K, Weber MA, Bakris GL, et al.

Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med ; Intensive diabetes therapy and glomerular filtration rate in type 1 diabetes.

Fullerton B, Jeitler K, Seitz M, et al. Intensive glucose control versus conventional glucose control for type 1 diabetes mellitus. Cochrane Database Syst Rev ; :CD Fioretto P, Steffes MW, Sutherland DE, et al.

Reversal of lesions of diabetic nephropathy after pancreas transplantation. Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial.

The Diabetes Control and Complications DCCT Research Group. Kidney Int ; Hemmingsen B, Lund SS, Gluud C, et al. Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Amod A, Buse JB, McGuire DK, et al.

Glomerular Filtration Rate and Associated Risks of Cardiovascular Events, Mortality, and Severe Hypoglycemia in Patients with Type 2 Diabetes: Secondary Analysis DEVOTE Diabetes Ther ; Davis TM, Brown SG, Jacobs IG, et al.

Determinants of severe hypoglycemia complicating type 2 diabetes: the Fremantle diabetes study. J Clin Endocrinol Metab ; Alsahli M, Gerich JE. Hypoglycemia, chronic kidney disease, and diabetes mellitus.

Mayo Clin Proc ; Flynn C, Bakris GL. Noninsulin glucose-lowering agents for the treatment of patients on dialysis. Nat Rev Nephrol ; Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy.

The Collaborative Study Group. Hebert LA, Bain RP, Verme D, et al. Remission of nephrotic range proteinuria in type I diabetes.

Collaborative Study Group. Kasiske BL, Kalil RS, Ma JZ, et al. Effect of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis.

Ann Intern Med ; Parving HH, Hommel E, Jensen BR, Hansen HP. Long-term beneficial effect of ACE inhibition on diabetic nephropathy in normotensive type 1 diabetic patients. Lewis EJ, Hunsicker LG, Clarke WR, et al.

Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes.

Berl T, Hunsicker LG, Lewis JB, et al. Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. J Am Soc Nephrol ; Pohl MA, Blumenthal S, Cordonnier DJ, et al. Independent and additive impact of blood pressure control and angiotensin II receptor blockade on renal outcomes in the irbesartan diabetic nephropathy trial: clinical implications and limitations.

Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. Parving HH, Lehnert H, Bröchner-Mortensen J, et al.

The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. Patel A, ADVANCE Collaborative Group, MacMahon S, et al.

Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus the ADVANCE trial : a randomised controlled trial.

Lancet ; Kaplan NM. Vascular outcome in type 2 diabetes: an ADVANCE? Bakris GL, Berkwits M. Trials that matter: the effect of a fixed-dose combination of an Angiotensin-converting enzyme inhibitor and a diuretic on the complications of type 2 diabetes. Barnett AH, Bain SC, Bouter P, et al.

Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. Mann JF, Schmieder RE, McQueen M, et al.

Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk the ONTARGET study : a multicentre, randomised, double-blind, controlled trial.

Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy.

Mann JF, Anderson C, Gao P, et al. Dual inhibition of the renin-angiotensin system in high-risk diabetes and risk for stroke and other outcomes: results of the ONTARGET trial. J Hypertens ; Parving HH, Brenner BM, McMurray JJ, et al.

Cardiorenal end points in a trial of aliskiren for type 2 diabetes. American Diabetes Association. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes Diabetes Care ; S Office of Patient Education. Chronic kidney disease treatment options. Coping effectively: A guide for patients and their families.

National Kidney Foundation. Robertson RP. Pancreas and islet cell transplantation in diabetes mellitus. Accessed May 25, Ami T. Allscripts EPSi. Mayo Clinic. June 27, Castro MR expert opinion. June 8, Chebib FT expert opinion. Mayo Clinic Press Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press.

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International Patients. And you might need to have further tests. If you want more information whilst you wait, call our helpline and speak to one of our advisors for answers and support. Some people are being sent, by their healthcare team, a home-based test that allows you to measure your albumin and creatinine concentrations in a sample of your urine, and your albumin-to-creatinine ratio ACR.

To do the test, you'll need the testing kit that's been designed to use with the app and need to pre-register using a unique link sent by your team.

The app guides you step-by-step through the testing process. You put a dipstick into your urine and take a photo of it using your smartphone. Computer vision algorithms are used to analyse the sample and give an accurate reading.

After the analysis, the results are automatically sent to your patient electronic record so they can be reviewed by your doctor. You can find out more on the NHS website. Your GP may also give you an Information Prescription , developed by us, which can help you understand your test results and develop an action plan.

You may be given tablets, such as ACE inhibitors or ARBs, to help with this. Both ACE inhibitors and ARBs help to protect the kidneys from further damage, as well as lower blood pressure.

If you do develop late-stage kidney disease and your kidneys fail, your treatment options include dialysis or a kidney transplant.

The good news is, as treatments and early diagnosis continues to improve, fewer people will go on to develop late-stage kidney disease. Talk with your diabetes team. They should be able to answer most of your questions.

If you have more questions, or just want someone to listen, give our helpline a call. The National Kidney Federation have kidney disease leaflets and can put you in touch with a local group.

Diabetic kidney disease Disclosures. Kidnry read the Disclaimer kieney Diabetic kidney disease end of this page. DIABETIC KIDNEY Diabetes pill options OVERVIEW. People with diabetes have a lot to juggle when it comes to their health care. Having diabetes puts you at risk of other health problems, including heart attacks, strokes, vision loss, nerve damage, and kidney disease. Diabetic nephropathy is a Diabetic kidney disease complication of type 1 Joint health conditions and type 2 diabetes. It's also called Metabolism Boosting Supplements Diiabetic disease. In the United Diabtic, about 1 in disrase people Metabolism Boosting Supplements with diabetes have 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 Diabetkc chance of complications.