Chapter 22: Diabetic Nephropathy

Diabetic nephropathy is the leading cause of CKD and ESRD, affecting nearly 40% of patients with diabetes. It progresses through predictable stages.

GFR increases 20-40% above normal. Kidneys enlarge. Clinically silent.

GFR normalizes, but structural changes like basement membrane thickening begin.

First clinical sign (albumin 30-300 mg/day). Represents the last potentially reversible stage.

Protein >300 mg/day. GFR begins to decline steadily.

GFR <15 mL/min/1.73m², requiring RRT.

Management involves a multi-pronged approach:

Glucose Control: Target HbA1c <7%.
Blood Pressure Control: Target <130/80 mmHg.
RAAS Inhibition: First-line therapy with ACE inhibitors or ARBs.
SGLT2 Inhibitors: Now a cornerstone of therapy for both kidney and cardiovascular protection.
GLP-1 Agonists & Finerenone: Emerging protective therapies.