India has a high rate of diabetes, with 40.9 million new cases per year. Patients with diabetes are 17 times more likely to develop kidney disease compared to non-diabetics. Early detection of diabetic nephropathy, preferably at the microalbuminuria stage, can prevent or delay the onset of end-stage renal disease. Management includes tight control of blood sugar and blood pressure through medications like ACE inhibitors. Regular screening and treatment of infections can help prevent further kidney damage.

1. Diabetic Nephropathy- epidemiology and prevention
Greetings from Dr Vilas Naik. This is our second brochure on nephrology update,
first one being Renal Calculus Disease.
Epidemiology (Diabetes type 2):
India is the diabetic capital of the world and 95 % is type 2 Diabetes.
1. There were 19 million/yr new diabetic patients in 1995 and now its 40.9 million
new patients/ year in 2007. So its rapidly increasing
2. 11% of India’s urban population and 3% of rural population above the age of 15
yrs are diabetics
3. WHO estimates: mortality from DM and heart disease cost India about 84000
crores (lost productivity, resulting primarily from premature death).

2. Epidemiology of Diabetic Nephropathy:
Diabetic patients are 17 times more likely to develop kidney disease as compared
to non- diabetics.
1. most common cause of End stage renal disease- upto 40 % of the patients on
dialysis are diabetic
2. Once proteinuria develops, the patients will have renal failure (rising creatinine)
in < 3 years
3. Once creatinine starts rising, (> 2 mg %), most patients end up on dialysis in next
2.5 years
Early detection:
1. According to the above data, now we all know that the earliest time to detect and
aggressively treat diabetic nephropathy is the stage of proteinuria
2. Even before the dipstick becomes positive, there is always a stage of
microalbuminuria (urinary proteinuria 30 to 300 mg/ day). This can be tested
using the MICRAL TEST.
3. If we detect diabetic nephropathy at the stage of microalbuminuria, we may be
able to prevent development of significant proteiuria and prevent or delay the
onset of renal failure/ dialysis
4. We all know that dialysis and kidney transplant are expensive treatments and so
the best management is early detection, preferably at the stage of
microalbuminuria, and take aggressive measures to prevent development of End
stage renal disease.
Management
1. Diagnosis:
a. Check urine and Sr creatinine at diagnosis of diabetes and every 6 monthly
there after.
b. Also evaluate for diabetic retinopathy yearly, this can help to prevent
blindness. Also diabetic retinopathy and nephropathy go together.
c. Check lipid profile every year.
2. Treatment:
a. Tight control of blood sugars, home blood sugar monitoring using
glucometer should be promoted

3. b. Tight control of Blood pressure is very important: BP should be < 125/75
to prevent progression of diabetic nephropathy
c. Angiotensin converting enzyme inhibitors like enalapril, ramipril or
lisinopril, and Angiotensin receptor inhibitors like losartan, telmisartan or
olmesartan are the first drugs of choice for BP control.
d. These drugs have effect of lowering BP, as well as decreasing proteinuria
and slowing the progression of diabetic nephropathy
e. An important caution before using these drugs : it is necessary to check Sr
creatinine and Sr potassium, before starting, one week and one month after
starting the treatment these drugs, especially in patients who have a
baseline creatinine >1.5 mg%. These drugs have risk of causing
hyperkalemia (high potassium) and cardiac arrythmias. Also risk of
sudden worsening of Sr creatinine in some patients
f. Statins like atorvastatin for cholesterol control, Sr LDL should be kept
<80 mg % in diabetics
g. Avoid drugs like NSAIDs and aminoglycosides (amikacin, gentamycin
etc) in diabetic patients
h. Treat infections aggressively. Especially patients developing UTI are
likely to develop significant complications- like renal failure. So urine
culture is a must.
i. Regular exercise, healthy diet, weight reduction, cessation of tobacco and
smoking will all help
Hope this information helps you in your practice and in better management of our
patients with diabetic kidney disease
Thanks
Dr Vilas Naik, MD, DM (Nephrology)
Fellowship in Nephrology and Kindey Transplant
University of Toronto, Canada
Formula for eGFR calculation:
(140 -- age) X weight ( multiply by 0.85 for females)
72 X serum creatinine