Diabetic nephropathy characterizes a huge chunk of any nephrologist's practice. Some of the issues to tackle with each visit are obvious--e.g., adequate glucose control, minimization of proteinuria, control of blood pressure--and generally much easier to talk about than to actually achieve. A Danish group in 1999 published in the Lancet the Steno Trial in which outpatients with diabetic nephropathy and microalbuminuria were randomized to "standard therapy" versus an "intensive, multifactorial therapy" during which patients received more individualized attention to both medical and behavioral aspects of care. The "intensive, multifactorial" group showed a slower progression of diabetic nephropathy (as well as other diabetic complications).
The guidelines which were used in their clinic--which can be found as a table in the most recent edition of NKF's KDOQI Guidelines--are the following:
1. BP < 130/80.
2. A1c < 6.5%.
3. total cholesterol < 175 mg/dL.
4. triglycerides < 150 mg/dL.
5. all patients on an ACE-inhibitor or an ARB, irrespective of blood pressure.
6. aspirin irrespective of cardiovascular disease history.
7. smoking cessation.
8. vitamin/mineral supplementation.
Although targeting weight loss was not part of their interventional strategy, there are many who believe that reducing BMI would also help reduce progression of diabetic nephropathy.
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