Diabetic nephropathy or overt proteinuria (macroalbuminuria, or "severely increased albuminuria") is usually present with worse glycemic control, hypertension, glomerular hyperfiltration, or in patients with a genetic predisposition.

The earliest clinical manifestation of renal involvement in diabetes is an increase in albumin excretion (microalbuminuria, or "moderately increased albuminuria").

Glycemic control can partially reverse the glomerular hypertrophy and hyperfiltration, delay the development of elevated albumin excretion, stabilize or decrease protein excretion in patients with increased albumin excretion, and can slow the progression of glomerular filtration rate decline.

ACE inhibitors OR ARBs can reduce the rate of kidney disease progression.

But, do not combine the two. Also, do not combine aliskiren, a direct renin inhibitor, with ACE inhibitors or ARBs.

Diabetic nephropathy with eGFR >30 mL/min per 1.73 m²  - add SGLT-2 inhibitor like canagliflozin or empagliflozin. They can reduce kidney disease progression, end-stage renal disease, and cardiovascular events and can potentially improve survival.

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA