Diabetische Nephropathie

Diabetic nephropathy, now often called diabetic kidney disease, is damage to the kidney's filters caused by years of raised blood sugar. It develops in roughly 1 in 3 people with diabetes and is the leading cause of kidney failure worldwide.

It is silent for a long time. The first sign is a small amount of albumin in the urine, found only by testing. Caught at that stage, progression can be slowed considerably with medicines that have strong trial evidence.

Symptome

• No symptoms in the early years
• Albumin in the urine on annual screening
• Rising blood pressure
• Ankle and leg swelling, foamy urine
• Falling insulin or tablet requirements with unexpected low sugars as kidney function drops
• Fatigue, nausea and itching in advanced disease
• Diabetic eye disease (retinopathy) is usually present as well

Ursachen und Risikofaktoren

High glucose raises pressure inside the glomeruli and triggers thickening and scarring of the filtering membrane. Risk increases with duration of diabetes, poor glucose control, high blood pressure, smoking, obesity, high cholesterol and family history, and is higher in people of South Asian, African, Hispanic and Indigenous ancestry. In type 1 diabetes it seldom appears before 5 to 10 years of disease. In type 2 it may already be present at diagnosis because the diabetes went unnoticed for years.

Wie es diagnostiziert wird

• Urine albumin to creatinine ratio: Checked yearly; two raised results out of three over 3 to 6 months confirm persistent albuminuria.
• eGFR: A yearly blood test tracking filtration.
• Retinal examination: Retinopathy supports the diagnosis. Its absence, especially in type 1 diabetes, raises the question of another kidney disease.
• Kidney ultrasound: Excludes obstruction and other structural causes.
• Kidney biopsy: Only when the picture is atypical: blood in the urine, sudden heavy proteinuria, a fast decline, or a short history of diabetes.

Behandlungsmöglichkeiten

• Glucose control: An individualised HbA1c target, commonly around 7 percent (53 mmol/mol), avoiding hypoglycaemia as kidney function falls.
• ACE inhibitor or ARB: First line when albuminuria is present, with or without high blood pressure.
• SGLT2 inhibitor: Reduces the risk of kidney failure and heart failure; can be started down to an eGFR of about 20.
• Finerenone: A non-steroidal mineralocorticoid blocker that adds protection in type 2 diabetes with albuminuria; potassium needs monitoring.
• GLP-1 receptor agonist: Semaglutide has shown kidney and cardiovascular benefit in type 2 diabetes and helps with weight.
• Blood pressure, lipids and lifestyle: Statin therapy, salt reduction, stopping smoking and regular activity.
• Reviewing diabetes medicines: Metformin dose is reduced below an eGFR of 45 and stopped below 30; sulfonylurea and insulin doses often need lowering.
• Kidney or kidney-pancreas transplant: For end-stage disease in suitable candidates.

Wenn es dringend ist

Get same day local care for very high sugars with vomiting or drowsiness, severe hypoglycaemia, sudden marked swelling or breathlessness, chest pain, or a sharp fall in urine output. Pause SGLT2 inhibitors, metformin and ACE inhibitors during dehydrating illness and seek advice.

Reisen nach Türkiye zur Behandlung

Protecting diabetic kidneys is a long game of three to six monthly reviews, so the main work has to happen where you live. A visit can provide a combined diabetes, kidney, eye and heart assessment over a few days and a written plan for your own doctors, which is useful if you have not been offered the newer protective medicines. People nearing kidney failure can be assessed for transplant with a living related donor. Do not expect a one-off treatment that reverses the damage; none exists.

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