Diabetic Nephropathy

Treatment Overview

Diabetic nephropathy is treated with medicines that lower blood pressure and protect the kidneys. These medicines may reverse kidney damage and are started as soon as any amount of protein is found in the urine (microalbuminuria). The use of these medicines before nephropathy occurs may also help prevent nephropathy in people who have normal blood pressure.^{5, 6}

If you have high blood pressure, two or more medicines may be needed to lower your blood pressure enough to protect the kidneys. Medications are added one at a time as needed. The Canadian Diabetes Association recommends a target blood pressure of less than 130/80 millimetres of mercury (mm Hg).⁴ The level recommended by other organizations may vary. Talk with your doctor about what your target blood pressure level should be. For more information on blood pressure medicines, see the topic High Blood Pressure (Hypertension).

If you take other medicines, avoid ones that damage or stress the kidneys, especially non-steroidal anti-inflammatory drugs (NSAIDs).

It is also important to keep your blood sugar as close to normal as possible. Maintaining blood sugar levels at a close to normal level prevents damage to the small blood vessels in the kidneys.

Limiting the amount of salt in your diet can help keep your high blood pressure from becoming worse. You may also want to restrict the amount of protein in your diet. Most health professionals recommend that protein make up no more than 10% of your daily calories. Talk with a dietitian if you need help balancing your diet.

People with diabetes are 2 to 4 times more likely than people who don't have diabetes to die of heart and blood vessel diseases. Using low-dose ASA therapy and eating a low-fat diet can help prevent heart attack, stroke, and other large blood vessel disease (macrovascular disease).⁷

Initial treatment

Medications that are used to treat diabetic nephropathy are also used to control blood pressure. If you have a very small amount of protein in your urine, these medicines may reverse the kidney damage. Medications used for initial treatment of diabetic nephropathy include:

• Angiotensin-converting enzyme (ACE) inhibitors, such as captopril, lisinopril, ramipril, and enalapril. ACE inhibitors have been shown to protect kidney function in people with type 1 diabetes, even in those who do not have high blood pressure.⁴ ACE inhibitors can lower the amount of protein being lost in the urine. In addition, they may reduce your risk of heart and blood vessel (cardiovascular) disease. One study found that ramipril cut the risk of cardiovascular disease in people with diabetes (type 1 and type 2 diabetes) by 25% to 30%.⁸
• Angiotensin II receptor blockers (ARBs), such as candesartan cilexetil, irbesartan, losartan potassium, and telmisartan. You may be given both an ACE inhibitor and an ARB. The combination of these medicines may provide greater protection for your kidneys than either medicine alone.

If you also have high blood pressure, two or more medicines may be needed to lower your blood pressure enough to protect your kidneys. Medications are added one at a time as needed. The Canadian Diabetes Association recommends a target blood pressure of less than 130/80 millimetres of mercury (mm Hg).⁴

If you take other medicines, avoid ones that damage or stress the kidneys, especially non-steroidal anti-inflammatory drugs (NSAIDs).

It is also important to maintain your blood sugar as close to normal as possible to prevent damage to the small blood vessels in the kidneys. The Canadian Diabetes Association recommends that you keep your blood sugar levels at:⁹¹⁰

• 4.0 millimoles per litre (mmol/L) and 7.0 mmol/L before meals.
• 5.0 and 10.0 mmol/L after eating and at bedtime.

People with diabetes are 2 to 4 times more likely than people who don't have diabetes to die of heart and blood vessel diseases. Eating a low-fat diet can help prevent heart attack, stroke, and other large blood vessel disease (macrovascular disease).⁴

Limiting the amount of salt in your diet can help keep your high blood pressure from becoming worse. You will also want to restrict the amount of protein in your diet. Most doctors recommend that protein make up no more than 10% of your daily calories. Talk with a dietitian if you need help balancing your diet.

Ongoing treatment

As diabetic nephropathy progresses, blood pressure usually rises, making it necessary to add additional medicines to control blood pressure. The goal set by the Canadian Diabetes Association is to keep your blood pressure less than 130/80 mm Hg, if possible, to protect your kidneys.⁴ The level recommended by other organizations may vary. Talk with your health professional about what your target blood pressure level should be.

Your health professional may recommend that you take the following medicines that lower blood pressure. You may need to take different combinations of these medicines to best control your blood pressure. By lowering your blood pressure, you may reduce your risk of kidney damage. Medications include:

• A combination of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). A combination of these medicines may be more effective in controlling blood pressure than either used alone.
• Calcium channel blockers lower blood pressure by making it easier for blood to flow through the vessels. Examples include diltiazem (such as Cardizem CD and Tiazac), verapamil (such as Covera-HS and Isoptin SR), amlodipine (such as Norvasc), and nifedipine (such as Adalat).
• Diuretics. Medications such as chlorthalidone, hydrochlorothiazide, or spironolactone help lower blood pressure by removing sodium and water from the body.
• Beta-blockers lower blood pressure by slowing down your heart beat and reducing the amount of blood pumped with each heart beat. Examples include atenolol (Tenormin), carvedilol (Coreg), or metoprolol (such as Lopresor).

If you take other medicines, avoid ones that may damage or stress the kidneys, especially non-steroidal anti-inflammatory drugs (NSAIDs).

It is also important to maintain your blood sugar as close to normal as possible to prevent damage to the small blood vessels in the kidneys. The Canadian Diabetes Association recommends that you keep your blood sugar levels at:⁹¹⁰

• 4.0 millimoles per litre (mmol/L) and 7.0 mmol/L before meals.
• 5.0 and 10.0 mmol/L after eating and at bedtime.

People with diabetes are 2 to 4 times more likely than people who don't have diabetes to die of heart and blood vessel diseases. Eating a low-fat diet can help prevent heart attack, stroke, and other large blood vessel disease (macrovascular disease).⁴

Limiting the amount of salt in your diet can help keep your high blood pressure from becoming worse. You will also want to restrict the amount of protein in your diet. Most doctors recommend that protein make up no more than 10% of your daily calories. Ask to speak with a dietitian if you need help balancing your diet.

People who have diabetic nephropathy also have an increased risk of illness and death from cardiovascular disease, so it is important to work with your health professional to reduce your risk of heart problems. Strategies include keeping your cholesterol at a normal level, using low-dose ASA therapy, getting regular exercise, and not smoking.

Treatment if the condition gets worse

If damage to the blood vessels in the kidneys continues, kidney failure eventually develops. When that occurs, it is likely that you will need dialysis treatment (renal replacement therapy)—an artificial method of filtering the blood—or a kidney transplant to survive. For more information, see the topic Chronic Kidney Disease.

What to think about

Diabetic nephropathy can get worse during pregnancy and can affect the growth and development of the fetus. If your nephropathy is not severe, your kidney function may return to its pre-pregnancy level after the baby is born. If you have severe nephropathy, pregnancy may lead to permanent worsening of your kidney function.¹¹

If you have nephropathy and are pregnant or are planning to become pregnant, talk with your health professional about which medicines you can take. You may not be able to take some medicines (for example, angiotensin-converting enzyme [ACE] inhibitors, such as captopril, lisinopril, ramipril, or enalapril) during pregnancy, because they may harm your developing baby. Talk to your health professional about your medicines and your plan to become pregnant.

Prevention

Prevention is the best way to avoid kidney damage from diabetic nephropathy.

• Keep your blood glucose levels as close to normal as possible. Manage your blood sugar by eating a balanced diet, taking your medicines (insulin or oral medicines), and getting regular exercise. The Canadian Diabetes Association recommends that you keep your blood sugar levels at:¹²
  • 4.0 millimoles per litre (mmol/L) and 7.0 mmol/L before meals.
  • 5.0 and 10.0 mmol/L after eating and at bedtime.
  Your health professional will want you to check your blood sugar several times each day. For more information, see:

  Home blood sugar monitoring.

• Have yearly testing for protein in your urine.
  • If you have type 1 diabetes, begin urine tests for protein after you have had diabetes for 5 years.
  • Children with type 1 diabetes should begin yearly urine protein screening beginning at puberty.
  • If you have type 2 diabetes, begin screening at the time diabetes is diagnosed.
• Maintain blood pressure at less than 130/80 mm Hg with medicine, diet, and exercise. Learn to check your blood pressure at home. For more information, see:

  Monitoring your blood pressure at home.

• Maintain a healthy weight. This can help you prevent other diseases, such as high blood pressure and heart disease. For more information, see the topic Healthy Weight.
• Follow the nutrition guidelines for hypertension (including the Dietary Approaches to Stop Hypertension, or DASH, diet). For more information, see:

  Tips for following the Dietary Approaches to Stop Hypertension (DASH) diet.

• Do not smoke or use other tobacco products. For more information, see the topic Quitting Tobacco Use.

If you already have diabetic nephropathy, you may be able to slow the progression of kidney damage by:

• Avoiding dehydration by promptly treating other conditions—such as diarrhea, vomiting, or fever—that can cause it. Be especially careful during hot weather or when you exercise.
• Reducing your risk of heart disease. Lifestyle changes such as eating a low-fat diet, quitting smoking, and getting regular exercise can help reduce your overall risk of developing heart disease and stroke. For more information, see the topics Healthy Eating and Fitness.
• Treating other conditions that may block the normal flow of urine out of the kidneys, such as kidney stones, an enlarged prostate, or bladder problems.
• Avoiding the use of medicines that may be harmful to your kidneys, especially non-steroidal anti-inflammatory drugs (NSAIDs). Be sure that your health professional knows about all prescription, non-prescription, and herbal medicines you are taking.
• Avoiding X-ray tests that require IV contrast material, such as angiograms, intravenous pyelography (IVP), and some CT scans. IV contrast can cause further kidney damage. If you do need to have these types of tests, make sure your health professional knows that you have diabetic nephropathy.
• Avoiding situations where you risk losing large amounts of blood, such as unnecessary surgeries. Do not donate blood or plasma.
• Lowering your blood pressure, because high blood pressure can make kidney damage even worse.
• Limiting alcohol to 1 drink per day for women and older adults and 2 drinks per day for men. Limiting alcohol can lower your blood pressure and lower your risk of kidney damage.

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Author:	Robin Parks, MS	Last Updated: February 13, 2007
Medical Review:	D.C. Mendelssohn, MD, FRCPC - Nephrology Anne C. Poinier, MD - Internal Medicine Michael Mallea, MD - Nephrology
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