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.

📚 Verified Sources — Chapter 19 (Diabetic Nephropathy)

Rossing P, et al; KDIGO 2022 DM-CKD WG. KDIGO 2022 Diabetes-CKD Guideline. Kidney Int. 2022;102(5S):S1-S127. PMID: 36272755.

Perkovic V, et al; CREDENCE. Canagliflozin in T2D nephropathy. N Engl J Med. 2019;380(24):2295-2306. PMID: 30990260.

Heerspink HJL, et al; DAPA-CKD. Dapagliflozin in CKD. N Engl J Med. 2020;383(15):1436-1446. PMID: 32970396.

Bakris GL, et al; FIDELIO-DKD. Finerenone in T2D-CKD. N Engl J Med. 2020;383(23):2219-2229. PMID: 33264825.

Pitt B, et al; FIGARO-DKD. Finerenone CV outcomes. N Engl J Med. 2021;385(24):2252-2263. PMID: 34449181.

Perkovic V, et al; FLOW. Semaglutide in T2D-CKD. N Engl J Med. 2024;391(2):109-121. PMID: 38785209.

Brenner BM, et al; RENAAL. Losartan in T2D nephropathy. N Engl J Med. 2001;345(12):861-869. PMID: 11565518.

📚 Verified Sources — Chapter 19 (Diabetic Nephropathy)