Standard Treatment of Diabetic Nephropathy ( EGFR > 30): ACE Inhibitor OR AR Blocker PLUS SGLT-2 Inhibitor
Dr KK Aggarwal
President CMAAO and HCFI
Diabetic nephropathy or overt proteinuria (macroalbuminuria, or "severely increased albuminuria") is usually present with worse glycemic control, hypertension, glomerular hyperfiltration, or a genetic predisposition.
The earliest clinical manifestation of renal involvement in diabetes is an increase in albumin excretion (microalbuminuria, or "moderately increased albuminuria")
Glycemic control can partially reverse the glomerular hypertrophy and hyperfiltration, delay the development of elevated albumin excretion, stabilize or decrease protein excretion in patients with increased albumin excretion, and \can slow the progression of glomerular filtration rate decline.
ACE inhibitors OR ARBs can reduce the rate of kidney disease progression.
Do not combiner the two.
Also do not combine aliskiren, a direct renin inhibitor with ACE or ARBs.
Diabetic nephropathy with EGFR >30 mL/min per 1.73 m2 add SGLT-2 inhibitor canagliflozin or empagliflozin. They can reduce kidney disease progression, end-stage renal disease, and cardiovascular events and can potentially improve survival. However, they increase the rate of urinary tract infections and genital fungal infections and may increase the likelihood of lower limb amputation and fracture. SGLT-2 inhibitors are weak glucose-lowering agents and also costly.