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What is the current treatment of Diabetic Nephropathy?
In addition to glycemic control as noted previously, inhibition of the renin-angiotensin-aldosterone system, sodium restriction, and blood pressure control are important parts of treating Diabetic Nephropathy.
Renin Angiotensin System (RAS) Inhibition
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have been a critical component of treating DN for more than 2 decades.
Intrarenal RAS activation plays a major role in the pathogenesis and progression of DN. ACE inhibitors have been studied both early and late in the course of type 1 DN and have been shown to slow the rate of estimated glomerular filtration rate (eGFR) decline and decrease the risk of ESKD.
Both ARBs and ACE inhibitors have been shown to do the same in patients with type 2 DN. In addition, since the importance of RAS inhibition in treatment of DN was discovered, there appears to be a slowing of the incidence of ESKD from DN in multiple regions of the world.
Sodium Restriction
High dietary sodium intake can cause hypervolemia and hypertension, leading to adverse cardiovascular outcomes. In addition, sodium restriction has been found to enhance the antiproteinuric effects of RAS inhibition.
Blood Pressure Control
Lowering blood pressure, even without using RAS inhibition, has been shown to decrease the rate of albumin excretion. Current guidelines from the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Task Force suggest a goal blood pressure of less than 130/80 mm Hg for diabetic patients.
This recommendation is based on the assumption that the vast majority of adults with DM (and CKD) have a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥ 10%.
This is a departure from the 2014 Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) which recommended a goal blood pressure of less than 140/90 mm Hg.
