Blood pressure control

Several large scale land mark clinical randomised control trials have consistently demonstrated the benefit of BP lowering and incident nephropathy (defined as progression of albuminuria and/or worsening of serum creatinine).28, 173, 216 A target blood pressure of 130/80 mmHg appears reasonable.^217-218 The benefit of further blood pressure lowering is unproven and may potentially be hazardous in individuals with pre-existing coronary artery disease.174-175, 219-220 To reduce the risk or slow

Blockade of the rennin-angiotensin-aldosterone system using angiotensin-converting enzyme (ACE) inhibitor²²¹ or angiotensin receptor blocker^{182, 222} (ARB) has been shown to reduce the risk or slow the progression of diabetic nephropathy.²²³ Therefore, it is recommended that in the treatment of the non-pregnant patient with micro- or macroalbuminuria, either ACE inhibitors or ARBs should be used.

A

It is recommended that in the treatment of the non-pregnant patient with micro- or macroalbuminuria, either angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should be used.182, 221-223

Grade A, Level 1⁺

While there are no adequate head-to-head comparisons of ACE inhibitors and ARBs, there is clinical trial support for each of the following three circumstances:

A

In patients with type 1 diabetes, with hypertension and any degree of albuminuria, angiotensin-converting enzyme (ACE) inhibitors are recommended.²²¹

Grade A, Level 1⁺

A

In patients with type 2 diabetes, hypertension, and microalbuminuria, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are recommended.^{182, 222}

Grade A, Level 1⁺

A

In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dl), angiotensin receptor blockers (ARBs) are recommended.^{182, 222}

Grade A, Level 1⁺

D

In patients with diabetes, if one class [either angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)] is not tolerated, the other should be substituted.

Grade D, Level 4

ACE inhibitor and ARB combination can further reduce proteinuria.²²⁴ However, there is insufficient data from clinical randomised control trial to routinely recommend this combination for the purpose of renal retardation.²²⁵ When ACE inhibitors, ARBs, or diuretics are used, it is recommended to monitor serum creatinine and potassium levels for the development of acute kidney disease and hyperkalemia.

A few evolving therapeutic agents have shown promise in anti-proteinuria or renal retardation. These include rennin antagonist,²²⁶ aldosterone receptor antagonist,²²⁷ fibrates,²²⁸ vitamin-D analogue²²⁹ and bardoxolone methyl.²³⁰ However, confirmatory large scale clinical studies are awaited. When diuretics, ACE inhibitors or ARBs are used, monitor serum sodium, potassium and creatinine levels for the development of hyponatremia, hyperkalemia and acute kidney disease.

D

When angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) or diuretics are used, it is recommended to monitor serum creatinine and potassium levels for the development of acute kidney disease and hyperkalemia.

Grade D, Level 4

Lipids management

Optimising blood lipids (especially with statins) may be modestly helpful in retarding progression of renal impairment.²³¹ More importantly, lipid lowering therapy also helps to reduce the cardiovascular burden in diabetic nephropathy. A recent landmark clinical trial suggested that LDL-cholesterol lowering could safely reduce the incidence of major atherosclerotic events in CKD.¹⁸⁴ Therefore, lipids management in diabetic nephropathy should adhere to existing guidelines recommended for diabetic individuals.

Protein restriction

A

Reduction of protein intake to 0.8–1.0 g per kg body wt per day in individuals with diabetes and earlier stages of chronic kidney disease (CKD) and to 0.8 g per kg body wt per day in the later stages of CKD is recommended to improve measures of renal function (urine albumin excretion rate, GFR).^232-233

Grade A, Level 1⁺

Anti-platelet therapy

Aspirin is recommended for the prevention of CVD in patients with a history of vascular disease (secondary prevention). In contrast, the efficacy of aspirin in the primary prevention of CVD among diabetic individuals is less established.²³⁴ Nevertheless, subgroup analysis from one large Asian clinical trial suggested that mild diabetic nephropathy (eGFR 60–89 mL/min/1.73 m²) may benefit from aspirin.²³⁵ Therefore, it appears reasonable to consider low-dose aspirin in diabetic individuals with significant cardiovascular burden (e.g., estimated 10 year risk of CVD >10%).²³⁶ It is recommended to consider low-dose aspirin in diabetic individuals with history of vascular disease or who carry a significant cardiovascular risk burden.

A

It is recommended to consider a low-dose aspirin in diabetic individuals with a history of vascular disease.

Grade A, Level 1⁺

D

It is recommended to consider low-dose aspirin in diabetic individuals who carry significant cardiovascular risk burden.

Grade D, Level 4

Monitoring

Continual monitoring of urine albumin excretion to assess both response to therapy and progression of disease is recommended.

Although not rigorously tested in clinical trials, substantial reduction in albuminuria (e.g., 50% reduction of the pre-intervention value) is considered a desirable therapeutic goal. When estimated GFR (eGFR)

D

Continual monitoring of urine albumin excretion to assess both response to therapy and progression of disease is recommended for both type 1 and type 2 diabetes patients.

Grade D, Level 4

D

It is recommended that when estimated GFR (eGFR) is <60 ml.min/1.73 m², evaluate and manage potential complications of chronic kidney disease.

Grade D, Level 4

Referral to specialist

It is recommended to consider referral to a physician experienced in the care of kidney disease when there is:

1) uncertainty about the etiology of kidney disease (heavy proteinuria, active urine sediment, absence of retinopathy, rapid decline in GFR),

2) difficult management issues (blood pressure, hyperkalemia control),

3) advanced kidney disease.

D

It is recommended to consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease (heavy proteinuria, active urine sediment, absence of retinopathy, rapid decline in GFR), difficult management issues, or advanced kidney disease.¹⁰⁵

Grade D, Level 4

9 Prevention and management of eye complications

Im Dokument Diabetes Mellitus (Seite 109-114)