What is the role of glycemic control in the treatment of Diabetic Nephropathy?
Type 1 DM and type 2 DM have a different pathogenesis, but both are associated with hyperglycemia.
Hyperglycemia activates the intrarenal renin-angiotensin system that plays an important role in the development of DN. However, the role of glycemic control in treatment of established DN is controversial.
The best evidence for preventing Diabetic Nephropathy is in patients with type 1 DM.
Tight glycemic control in patients with type 1 DM decreases the risk of development of albuminuria.
In individuals with type 1 DM and moderately increased albuminuria, tight glycemic control also reduces the risk of progression to nephropathy.
In addition, once severely increased albuminuria is present, small studies have found that return to euglycemia by performing a pancreas transplant led to improvement of biopsy findings 10 years post transplant.
In type 2 DM the data is less certain.
Tight glycemic control appears to decrease the risk for development of moderately and severely increased albuminuria but does not decrease the risk for doubling of serum of creatinine or of renal death.
In addition, tight blood glucose control to a hemoglobin A1c (HbA1C) less than 6.5% resulted in increased mortality.
The current goal HbA1c in patients with DKD is less than 7%, with liberalized goals for elderly patients or those prone to hypoglycemia.
