Diabetic nephropathy

Nephropathy is a potentially devastating complication of diabetes causing much morbidity and associated with a considerable risk of premature cardiovascular mortality. Early identification and aggressive treatment is essential. The earliest phase is persistent microalbuminuria and this phased itself is associated with loss of renal function and increased cardiovascular risk especially in type 2 diabetes. At the phase of dipstick positive proteinuria so-called overt nephropathy these risks accelerate leading if untreated to end-stage renal failure or premature cardiovascular death. Treatment is by improved blood glucose control and antihypertensive therapy. Treatment with renin-angiotensin system inhibitors may be prescribed with a target BP of at least 130/80 mmHg (125/75 in younger patients). Lipid lowering therapy is indicated and smoking cessation should be advocated. Consideration of the development of anaemia and bone disease should be made. Joint care by diabetes and renal specialists should be considered when a patient's serum creatinine concentration reaches 150 µmol/litre or eGFR around 30-50ml/min, and plans for renal replacement therapy should be made. Specialists should agree on management protocols for end-stage renal failure on a regional, district or institutional basis, and review and update them at regular intervals. Proteinuria during pregnancy and pregnancy in patients with diabetic proteinuria requires special attention and should be managed by a joint team of specialists. Counselling and education of patients and briefing of primary health care providers should be provided throughout all phases of diabetic kidney disease.