Volume 2, Issue 2, March 2014, Page: 26-33
Preventing the Progression of Diabetic Kidney Disease
Sheikh Salahuddin Ahmed, Department of Internal medicine, Bangladesh Institute of Health Sciences (BIHS), Dhaka, Bangladesh
Received: Feb. 5, 2014;       Published: Mar. 20, 2014
DOI: 10.11648/j.ajim.20140202.14      View  3014      Downloads  238
Diabetic kidney disease (DKD) is a progressive condition and is an important cause of end-stage renal disease (ESRD) causing increased morbidity and mortality. The objective of this review article is to discuss about recognition and treatment of early DKD to prevent its progression. Informations have been gathered from related clinical studies, research works, articles, abstracts, and guidelines of different organizations published in various journals. Microalbuminuria describes the urinary excretion of small amounts of albumin which identifies the early stage of DKD. In addition to an earliest marker of kidney damage, microalbuminuria is an established high risk factor for cardiovascular morbidity and mortality. Patients with microalbuminuria who progress to macroalbuminuria are likely to progress to ESRD. There is general agreement that people with diabetes should be screened regularly to detect early markers of kidney damage. Albumin creatinine ratio in a morning urine sample is the preferred method of detecting microalbuminuria in diabetes. There is strong evidence that a number of interventions if initiated at early stage of DKD reduces the risk and slows the progression of kidney damage. People with diabetes and microalbuminuria should be treated with a multifactorial intervention approach to retard the progression of DKD. Studies have clearly demonstrated that the use of angiotensin converting enzyme inhibitors or angiotensin 2 receptor blockers with improved glycemic control, blood pressure control, lipid lowering, aspirin, smoking cessation, exercise programs and dietary intervention reduced the development of overt nephropathy and ESRD.
Diabetic Kidney Disease, Macroalbuminuria, Microalbuminuria
To cite this article
Sheikh Salahuddin Ahmed, Preventing the Progression of Diabetic Kidney Disease, American Journal of Internal Medicine. Vol. 2, No. 2, 2014, pp. 26-33. doi: 10.11648/j.ajim.20140202.14
Molitch ME, DeFronzo RA, Franz MJ, Keane WF, Mogensen CE, Parving HH, et al. Nephropathy in Diabetes. American Diabetes Association Position Statement. Diabetes Care 2004 Jan;27(Suppl 1):S79-83.
International Diabetes Federation, 2012 Clinical Guidelines Task Force Global Guideline for Type 2 Diabetes. Available from:http://www.societate-diabet.ro/pdf/Global-Guideline-for-Type-2-Diabetes-IDF-2012.pdf
Rashid HU: Bangladesh Renal Registry Report 1986-1996. Bang Renal J. 2002;21(1): 25-28.
Sakhuja V, Sud K. End Stage Renal Disease in India and Pakistan: burden of disease and management issues. Kidney Int. Suppl 2002;83:S115-118.
Garg JP, Bakris GL. Microalbuminuria: marker of vascular dysfunction, risk factor or cardiovascular disease. Vasc Med 2002;7:35–43.
Scottish Intercollegiate Guidelines Network. Management of diabetes. A national clinical guideline. March 2010. Available from http://www.sign.ac.uk/pdf/sign116.pdf
Klausen K, Borch-Johnsen K, Feldt-Rasmussen B, Jensen G, Clausen P, Scharling H, et al. Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes. Circulation 2004;110:32–35.
Gall MA, Hougaard P, Borch-Johnsen K, Parving HH. Risk factors for development of incipient and overt diabetic nephropathy in patients with non-insulin dependent diabetes mellitus: prospective, observational study. BMJ 1997;314:783–788.
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2013;36(Suppl 1):S11-S66.
National Kidney Foundation. K/DOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis. 2007;49(2 suppl 2):S1-179. Available from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/
UK CKD guidelines consultation draft 9th December 2005. Available from http://www.kidney.org.uk/main/guidelines/UKCKD_guidelines_consultation_draft.pdf
NICE clinical guidelines. CG73 Chronic kidney disease. Early identification and management of chronic kidney disease in adults in primary and secondary care. Issued: September 2008. Available from http://publications.nice.org.uk/chronic-kidney-disease-cg73
Goddard J, Turner AN, Stewart LH. Kidney and urinary tract disease. In: Colledge NR, Walker BR S & Ralston SH. Davidson’s Principle and Practice of Medicine. 21st International ed. Churchill Livingstone Elsevier;2010:pp480-496.
Levin A, Hemmelgarn B, Culleton B, Tobe S, McFarlane P, Ruzicka M, et al. Guidelines for the management of chronic kidney disease. CMAJ 2008;179(11):1154-62.
Chadban S, Howell M, Twigg S, Thomas M, Jerums G, Alan C, et al. National Evidence Based Guideline for Diagnosis, Prevention and Management of Chronic Kidney Disease in Type 2 Diabetes. Diabetes Australia and the NHMRC, Canberra 2009.
Levey AS, Cattran D, Friedman A Miller WG, Sedor J, Tuttle K et al. Proteinuria as a surrogate outcome in CKD: report of a scientific workshop sponsored by the National Kidney Foundation and the US Food and Drug Administration. Am J Kidney Dis 2009; 54: 205–226.
Mussap M, Dalla Vestra M, Fioretto P, Saller A, Varagnolo M, Nosadini R et al. Cystatin C is a more sensitive marker than creatinine for the estimation of GFR in type 2 diabetic patients. Kidney Int 2002; 61: 1453–61.
Herget-Rosenthal S, Marggraf G, Hüsing J, Göring F, Pietruck F, Janssen O, et al. Early detection of acute renal failure by serum cystatin C. Kidney Int 2004; 66: 1115–22.
Spanaus KS, Kollerits B, Ritz E, Hersberger M, Kronenber F, von Ekardstein A. Serum creatinine, cystatin C, and beta-trace protein in diagnostic staging and predicting progression of primary nondiabetic chronic kidney disease. Clin Chem 2010; 56: 740–749.
Dharnidharka VR, Kwon C, Stevens G. Serum cystatin C is superior to serum creatinine as a marker of kidney function: a meta-analysis. Am J Kidney Dis 2002; 40: 221–226.
Nickolas TL, O'Rourke MJ, Yang J, Sise ME, Canetta PA, Barasch N et al. Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury. Ann Intern Med 2008; 148: 810–819.
Viau A, El Karoui K, Laouari D, Burtin M, Nguyen C, Mori K et al. Lipocalin 2 is essential for chronic kidney disease progression in mice and humans. J Clin Invest 2010; 120: 4065–4076.
Bolignano D, Lacquaniti A, Coppolino G, Donota V, Fazio MR, Nicocia G et al. Neutrophil gelatinase-associated lipocalin as an early biomarker of nephropathy in diabetic patients. Kidney Blood Press Res 2009; 32: 91–98.
Vaidya VS, Niewczas MA, Ficociello LH, Johnson AC, Collings FB, Warran JH et al. Regression of microalbuminuria in type 1 diabetes is associated with lower levels of urinary tubular injury biomarkers, kidney injury molecule-1, and N-acetyl-beta-D-glucosaminidase. Kidney Int 2011; 79: 464–470.
Han WK, Bailly V, Abichandani R, Thadhani R, Bonventre JV. Kidney injury molecule-1 (KIM-1): a novel biomarker for human renal proximal tubule injury. Kidney Int 2002; 62: 237–244.
Ko GJ, Grigoryev DN, Linfert D, Jang HR, Watkins T, Cheadle C et al. Transcriptional analysis of kidneys during repair from AKI reveals possible roles for NGAL and KIM-1 as biomarkers of AKI to CKD transition. Am J Physiol Renal Physiol 2010; 298: F1472–F1483.
Kamijo A, Sugaya T, Hikawa, Yamanouchi M, Hirata Y, Ishimitsu T et al. Clinical evaluation of urinary excretion of liver-type fatty acid-binding protein as a marker for the monitoring of chronic kidney disease: A multicenter trial. J Lab Clin Med 2005; 145: 125–33.
Nakamura T, Sugaya T, Kawagoe Y, Uede Y, Osada S, Koedi H. Effect of pitavastatin on urinary liver-type fatty acid-binding protein levels in patients with early diabetic nephropathy. Diabetes Care 2005; 28: 2728–2732.
Kamijo A, Sugaya T, Hikawa A, Yamanouchi M, Hirata Y, Ishimitsu T et al. Urinary liver-type fatty acid binding protein as a useful biomarker in chronic kidney disease. Mol Cell Biochem 2006; 284: 175–182.
Kamijo A, Kimura K, Sugaya T, Yamanouchi M, Hikawa A, Hirano N et al. Urinary fatty acid-binding protein as a new clinical marker of the progression of chronic renal disease. J Lab Clin Med 2004; 143: 23–30.
Wang G, Lai FM, Lai KB, Chow KM, Li KT, Szeto CC. Messenger RNA expression of podocyte-associated molecules in the urinary sediment of patients with diabetic nephropathy. Nephron Clin Pract. 2007; 106: c169–79.
Cumming A. The renal system. In Doglas G, Nicol F & Robertson C. Macleod’s Clinical Examination. 11th International ed. Churchill Livingstone Elsevier;2005:p193.
Alsaad KO, Herzenberg A M. Distinguishing diabetic nephropathy from other causes of glomerulosclerosis: an update. J Clin Pathol 2007 January;60(1):18–26.
Bash LD, Selvin E, Steffes M, Coresh J, Astor BC. Poor Glycemic Control in Diabetes and the Risk of Incident Chronic Kidney Disease Even in the Absence of Albuminuria and Retinopathy: Atherosclerosis Risk in Communities (ARIC) Study. Archives of Internal Medicine 2008;168(22): 2440-2447.
American Diabetes Association Position Statement: Diabetic Nephropathy. Diabetes Care 2003 Jan;26(Suppl 1):S94-S98.
The ACE Inhibitors in Diabetic Nephropathy Trialist Group. Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors: a meta-analysis of individual patient data. Ann Intern Med 2001;134(5):370-379.
Strippoli GFM, Bonifati C, Craig M, Navaneethan SD, Craig JC. Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease (Cochrane Review). In: The Cochrane Library, Issue 4, 2006. London: Wiley.
Kshirsagar AV, Joy MS, Hogan SL, Falk RJ, Colindres RE. Effect of ACE inhibitors in diabetic and nondiabetic chronic renal disease: a systematic overview of randomized placebo-controlled trials. Am J Kidney Dis 2000;35(4):695-707.
Strippoli GFM, Craig M, Craig JC. Antihypertensive agents for preventing diabetic kidney disease (Cochrane Review). In: The Cochrane Library, Issue 4, 2006. London: Wiley.
Mogensen CE, Neldam S, Tikkanen I, Oren S, Viskoper R, Watts RW, et al. Randomised controlled trial of dual blockade of the renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the Candesartan and Lisinopril Microalbuminuria (CALM) study. BMJ 2000;321:1440–4.
Schjoedt KJ, Jacobsen P, Rossing K, Boomsma F, Parving HH. Dual blockade of the renin-angiotensin-aldosterone system in diabetic nephropathy: the role of aldosterone. Horm Metab Res 2005;37(Suppl. 1):4–8.
Parving HH, Persson F, Lewis JB, Lewis EJ, Hollenberg NK; AVOID Study Investigators. Aliskiren combined with losartan in type 2 diabetes and nephropathy. N Engl J Med 2008;358:2433–2446.
Yusuf S, Teo KK, Pogue J, Dyal L, Copland I, Schumacher H et al; ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358:1547–1559.
National Kidney Foundation. KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 update. Am J Kidney Dis. 2012;60(5):850-886.
Kunz R, Friedrich C,Wolbers M, Mann JF. Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease. Ann Intern Med 2008 Jan 1;148(1):30-48.
Mann JF, Schmieder RE, McQueen M, Dyal L, Schumacher H, Pogue J et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomized, double blind, controlled trial. Lancet 2008 Aug 16;372(9638):547-553.
Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329(14):977-986.
UK Prospective Diabetes Study Group: Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352(9131):837-853.
The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358:2545-2559.
The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-2572.
Ismail-Beigi F, Craven T, Banerji MA, Basile J, Calles J, Cohen RM, et al. ACCORD Trial Group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet 2010;376:419–430.
American Diabetes Association. Standards of medical care in diabetes-2011. Diabetes Care 2011;34(Suppl 1):S11–S61
American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2003;26(suppl 1):S33–50.
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: (UKPDS 38). BMJ 1998;317:703–713.
Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355:253–259.
Levey AS. Clinical practice. Nondiabetic kidney disease. N Engl J Med 2002;347:1505–1511.
Hansen HP, Tauber-Lassen E, Jensen BR, Parving HH. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney Int 2002;62:220–228.
Kasiske BL, Lakatua JD, Ma JZ, Louis TA. A meta-analysis of the effects of dietary protein restriction on the rate of decline in renal function. Am J Kidney Dis 1998;31:954–961.
Fouque D, Wang P, Laville M, Boissel JP. Low protein diets for chronic kidney disease in non diabetic adults (Cochrane Review).In: The Cochrane Library, Issue 4, 2000. London: Wiley
Robertson L, Waugh N, Robertson A. Protein restriction for diabetic renal disease (Cochrane Review). In: The Cochrane Library, Issue 4, 2007. London: Wiley.
Keane WF. The role of lipids in renal disease: future challenges. Kidney Int Suppl 2000;75:S27-31.
Sukhija R, Bursac Z, Kakar P, Fink L, Fort C, Satwani S, et al. Effect of statins on the development of renal dysfunction. Am J Cardiol 2008;101(7):975-9.
Fried LF, Orchard TJ, Kasiske BL. Effect of lipid reduction on the progression of renal disease: a meta-analysis. Kidney Int 2001;59:260–9.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008; 32: S95-S98.
Gaede P, Vedel P, Parving HH, Pedersen O. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet 1999;353(9153):617-622.
Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358(6):580-591.
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