Diabetes – the modern-day epidemic, is one of the major causes of CKD. DKD is the single leading cause of ESRD requiring RRT (40-50%). Previous reports suggest that DKD is seen in about 31% of patients all over India. A recent report (2021) suggested that DKD is the most common cause (25%) of renal impairment in the subcontinent. 

DKD results in lower life expectancy (reduced by 6 years) compared to other diabetic patients. Moreover, almost half of the diabetic patients in India suffer from renal impairment. Hence, an early diagnosis and management are warranted. 

The diagnosis relies on assessing the kidney damage and function. Clinical diagnosis of CKD is defined as UACR >30 mg/g and eGFR <60 ml/min/1.73 m2––which persists for >3 months.

Established Therapy for DKD – ACE is/ARBs, SGLT2 is, ERA, Non-steroidal MRAs in cases with hemodynamic dysregulation; RAAS is in cases with inflammations; and GLP-1Ras and other OADs in cases with hyperglycemia.

Obesity is a major risk factor for DKD and associated complications. Semaglutide can be used in obese patients with DKD. 

Evidence-based Therapy for DKD – risk factor modification and patient education; RAS blockade; BP lowering; glycemic control; lipid-lowering; albuminuria reduction; and SGLT2 inhibition.

A timely, multifactorial, and individualized interventional approach should be employed for optimal risk reduction in patients with DKD. GLP-1RAs and ET-1s can be deemed as the additional pillars for DKD management. 

Novel Therapies – Imeglimin, is an oxidative phosphorylation blocker. Lifestyle modifications should be adopted as recommended by the KDIGO. 

Practical Therapeutic Approaches:

·        Optimal use of combination-drug therapy – three-drug treatment (RAS blockage, SGLT2 is, and Finerenone).

·        Avoid experimental therapies or pseudo-claims/supplements.

·        Do not restrict vegetarian protein to avoid protein-energy wasting.

·        Do not prescribe diuretics to individuals with lower serum creatinine.

·        Avoid the following drugs – NSAIDs, MRAs, COX-2 is, Aminoglycosides for UTIs, and Ayurvedic/herbal preparations.

·        Assess fiasco/acute impact before attributing changes in drug regimen.

Joint ADA-KDIGO Consensus Report:

Screening for DKD – Yearly for T1D patients, starting 5 years after diagnosis; and yearly for T2D patients, beginning at diagnosis. Investigations – eGFR and spot urine ACR tests. 

In case of a positive result – repeat and confirm; initiate evidence-based treatments. 

Confirmatory diagnoses on – persistent ACR ≥ 30 mg/g and/or persistent eGFR < 60 ml/min/1.73 m2 and/or other evidence of kidney damage. 

Summary:

DKD – a progressive disease, is associated with rising prevalence and high mortality rates. It poses widespread vascular disease risk for ASCVD, which increases with diabetes duration. The DKD complications are driven by hyperglycemia, HTN, and obesity. DKD is preventable with early diagnosis and timely intervention.