Diabetic Kidney Disease Management and Prevention

Epidemiology and Impact

Diabetic kidney disease affects 20-40% of people with diabetes and is the single leading cause of end-stage kidney disease in the United States, accounting for approximately 35% of the end-stage kidney disease population 3
Chronic kidney disease affects approximately 9% of the global population, with its impact substantial and rising due to the growing population of older adults and increasing incidence of obesity and diabetes 4
The American Diabetes Association recommends that diabetic kidney disease typically develops after a duration of 10 years in type 1 diabetes but may be present at diagnosis of type 2 diabetes 3
The presence of chronic kidney disease markedly increases cardiovascular risk and healthcare costs in patients with both type 1 and type 2 diabetes 3

Diabetic kidney disease is diagnosed by persistent albuminuria (>30 mg/24h or UACR >30 mg/g), persistent reduction in eGFR below 60 mL/min/1.73m², or both, for at least 3 months 1, 3
The typical presentation includes long-standing diabetes, retinopathy, albuminuria without gross hematuria, and gradually progressive loss of eGFR 3
The European Heart Journal classifies chronic kidney disease into five different stages based on GFR levels:

The American Diabetes Association recommends screening for albuminuria using urine albumin-to-creatinine ratio in a random spot urine collection 3, 2
Abnormal albuminuria is defined as microalbuminuria: 30-299 mg/g creatinine or macroalbuminuria: ≥300 mg/g creatinine 6
Due to variability in urinary albumin excretion, two of three specimens collected within a 3-6 month period should be abnormal before confirming diagnosis 6
Kidney function is best assessed with GFR according to the MDRD equation, which includes ethnicity and sex in its calculation 5

The risk of death from any cause, including cardiovascular disease, rises with progressive decrease of GFR, with a swift increase in events for GFR <60 mL/min/1.73m² 5
Renal dysfunction is frequently observed in non-ST-elevation acute coronary syndromes and is associated with worse prognosis 5
Chronic kidney disease complicates the management of and heightens mortality associated with many chronic conditions, such as cardiovascular disease and cancer 4

The American Diabetes Association recommends optimal glycemic control to delay the onset of microalbuminuria and the progression of micro- to macroalbuminuria in patients with both type 1 and type 2 diabetes 6
Blood pressure control, particularly with renin-angiotensin system blockade using ACE inhibitors or ARBs, is essential for slowing diabetic kidney disease progression 3, 1
For people with type 2 diabetes and chronic kidney disease, a sodium-glucose cotransporter 2 inhibitor is recommended to reduce chronic kidney disease progression and cardiovascular events 3, 2
A glucagon-like peptide 1 receptor agonist with demonstrated benefit is recommended for people with type 2 diabetes and chronic kidney disease to reduce cardiovascular risk and kidney disease progression 3
Protein intake should be 0.8 g/kg body weight per day for people with non-dialysis-dependent stage G3 or higher chronic kidney disease, and 1.0-1.2 g/kg/day for individuals on dialysis 3

Individuals should be referred for evaluation by a nephrologist if they have continuously increasing urinary albumin levels, continuously decreasing eGFR, or if the eGFR is <30 mL/min/1.73m² 3, 2
Consider referral when the GFR has fallen to <60 mL/min/1.73m² or if difficulties occur in the management of hypertension or hyperkalemia 6

Monitor for increased serum creatinine and potassium levels when ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists are used 3