Diabetic kidney disease
Diabetic kidney disease is the leading cause of chronic kidney disease and end-stage kidney disease worldwide, driven by chronic hyperglycemia acting through advanced glycation end products on the glomerulus. It is diagnosed clinically from progressive albuminuria and falling eGFR in a patient with long-standing diabetes and other microvascular disease, and treatment centers on RAS blockade, SGLT2 inhibition, and glycemic and blood pressure control.
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What this article covers
- Overview
Diabetic kidney disease (DKD) is clinical evidence of kidney injury from chronic hyperglycemia: progressive albuminuria, and in many patients a subsequent decline in glomerular filtration rate (GFR)…
- Epidemiology
DKD is detected in approximately 35% to 50% of patients with type 2 diabetes and about 10% of patients with type 1 diabetes.
- Risk factors
Long-standing diabetes duration, with cumulative hyperglycemic exposure over 5 to 10+ years the dominant driver.
- Pathophysiology
Advanced glycation end products (AGEs) are the primary mediator of glomerular injury in DKD, forming from chronic hyperglycemic exposure of proteins and lipids.
- Clinical features
Mildly increased albuminuria is the earliest manifestation, often asymptomatic and detected only by laboratory screening rather than by symptoms.
- Differential diagnosis
Focal segmental glomerulosclerosis: proteinuria without the long diabetes duration or concurrent retinopathy; confirmed on biopsy by segmental sclerosis rather than nodular mesangial sclerosis.
- Diagnosis
DKD is usually a clinical diagnosis: proteinuric CKD in a patient with long-standing diabetes plus evidence of other microvascular and/or macrovascular complications (most notably diabetic…
- Management
Start an ACE inhibitor or angiotensin receptor blocker (ARB) as first-line therapy in any patient with diabetes, hypertension, and either reduced eGFR (<60 mL/min/1.73 m2) or elevated UACR (=30…
- Complications
Progression to ESKD requiring dialysis or transplantation, the most serious outcome and the leading indication for dialysis initiation in the United States.
- Prognosis
Baseline eGFR and severity of albuminuria/proteinuria are the most important predictors of progression to ESKD; higher UACR category and lower eGFR category both independently predict faster decline.
- Prevention
Screen for albuminuria (UACR) annually starting at diagnosis in type 2 diabetes, and starting 5 years after diagnosis in type 1 diabetes, then annually.
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