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.
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