Diabetic Nephropathy — पूर्ण MBBS/MD-Level Guide (Hindi + English)
Updated: 19 August 2025 • Mahfooz Medical Health • Clinicians/Students/Patients
संक्षिप्त परिचय (Short overview)
Diabetic nephropathy (DKD) diabetes की chronic complication है जिसमें glomerular और tubulointerstitial damage होता है। Clinical hallmark persistent albuminuria (ACR ≥30 mg/g) और/या decline in eGFR (<60 mL/min/1.73m²)। Screening महत्वपूर्ण — annual ACR & eGFR recommended.
Clinical pearl: ACR abnormal होने पर 2 of 3 samples within 3–6 months से confirm करें — temporary albuminuria (fever, exercise, UTI) अलग है।
Pathophysiology — MBBS/MD level
मुख्य mechanisms:
- Hemodynamic: Afferent dilation + efferent constriction → intraglomerular hypertension, hyperfiltration.
- Metabolic: AGEs, polyol pathway, PKC activation → oxidative stress, TGF-β mediated fibrosis.
- Podocyte injury: Foot process effacement → proteinuria; podocyte loss → irreversible progression.
- Tubulointerstitial fibrosis: ischemia, chronic inflammation amplify GFR decline.
Histology: GBM thickening (EM), mesangial expansion, advanced: Kimmelstiel–Wilson nodules.
Clinical features, screening और staging
Early stage अक्सर asymptomatic रहता है — इसलिए screening जरूरी है।
- Screen: Spot urine ACR और serum creatinine (eGFR) annually.
- Symptoms (advanced): edema, nocturia, anorexia, fatigue, uremic features.
| Albuminuria (ACR) | Category |
|---|---|
| <30 mg/g | Normal |
| 30–300 mg/g | Moderately increased (microalbuminuria) |
| >300 mg/g | Severely increased (macroalbuminuria) |
KDIGO staging: G (eGFR) + A (albuminuria) combined se risk stratify करें।
Investigations — कौन-कौन से टेस्ट और क्यों
- Spot urine ACR: preferred screening; repeat to confirm persistence.
- eGFR (CKD-EPI): trend monitoring महत्वपूर्ण है.
- Urine microscopy — hematuria/active sediment suggests other glomerulonephritis.
- Electrolytes, bicarbonate, HbA1c, lipid profile, CBC, iron studies.
- Renal ultrasound — size/obstruction; consider biopsy if atypical features.
Atypical features (rapid decline, hematuria, short diabetes duration with heavy proteinuria) → consider serology (ANA/ANCA/complements) and renal biopsy.
Treatment pillars — मुख्य सिद्धांत
Objectives: slow progression, reduce proteinuria, reduce cardiovascular events, manage CKD complications.
- Tight but safe glycemic control (individualize HbA1c).
- BP control & RAAS blockade (ACEi/ARB) for albuminuric DKD.
- SGLT2 inhibitors for renal & CV protection (where indicated).
- Finerenone/GLP-1 RAs as per indications.
- Manage complications: anemia, acidosis, bone-mineral disorders, hyperkalemia, volume overload.
Medicines — Dose, Timing, Duration, Age & eGFR Adjustments (Practical)
नोट: नीचे दिए गए doses सामान्य guideline-level examples हैं। Final dose/therapy हमेशा treating clinician/nephrologist से confirm करें।
1. ACE inhibitors (RAAS blockade) — Enalapril / Lisinopril
- Enalapril: Start 2.5 mg OD → typical maintenance 5–20 mg/day (once daily or divided). Timing: once daily (morning). Duration: chronic (long-term) for albuminuria.
- Lisinopril: Start 5 mg OD → titrate to 20–40 mg OD as tolerated.
- Monitoring: Check creatinine & K+ at baseline and 1–2 weeks after initiation/change. Acceptable creatinine rise ≤30% from baseline. If K+ >5.5 mmol/L or creatinine rises excessively, reassess therapy.
- Contraindications: pregnancy (absolutely), bilateral renal artery stenosis, history of angioedema.
2. ARBs — Losartan / Valsartan
- Losartan: Usual dose 50 mg OD → up to 100 mg OD. Timing: once daily.
- Use when ACEi intolerance (cough, angioedema). Same monitoring as ACEi.
3. SGLT2 inhibitors — Empagliflozin / Dapagliflozin / Canagliflozin
- Empagliflozin: 10 mg OD (some indications 25 mg OD).
- Dapagliflozin: 10 mg OD.
- Timing: once daily (morning) — with or without food per product insert.
- Duration: Long-term for cardio-renal protection when indicated.
- eGFR guidance: Glycemic efficacy reduces at low eGFR but renal benefits often persist; follow local guideline eGFR thresholds (e.g., many guidelines permit use down to eGFR 25–30 for renal benefit). Always check label and local recommendations.
- Side-effects & counselling: genital mycotic infections (maintain hygiene), risk of volume depletion (monitor BP), rare euglycemic ketoacidosis — stop during acute illness, before major surgery or dehydration.
4. Finerenone (non-steroidal mineralocorticoid receptor antagonist)
- Example dosing: 10 mg OD → may up-titrate to 20 mg OD as per label and renal function.
- Monitoring: serum K+ regularly; avoid if baseline hyperkalemia. Specialist decision in many settings.
5. Metformin
- Typical dose: 500 mg BD → up to 2000 mg/day in divided doses (depending on tolerance).
- Timing: with meals to reduce GI side-effects.
- eGFR adjustments: eGFR ≥45: standard dosing; eGFR 30–45: reduce dose and monitor; eGFR <30: generally contraindicated — stop metformin.
6. Insulin
- Regimen individualized: basal (e.g., glargine/detemir) ± prandial (rapid-acting). In CKD, insulin clearance reduced → risk of hypoglycemia → reduce doses as eGFR declines.
- Timing: basal once daily (night or morning per regimen); prandial with meals.
7. Diuretics & volume control
- Loop diuretics (Furosemide): 20–80 mg OD or BD, titrate to effect for edema/volume overload. Thiazides lose efficacy eGFR <30; metolazone can be used in combination for refractory edema.
8. Statins (CV risk)
- High/moderate-intensity statins as per ASCVD risk profile and CKD stage — continue unless contraindicated.
9. Hyperkalemia — acute & chronic strategies
- Acute: IV calcium gluconate (to stabilize myocardium), IV insulin + dextrose, nebulized salbutamol, IV bicarbonate if indicated, examine ECG.
- Chronic recurrent: potassium binders (patiromer, sodium zirconium cyclosilicate) to allow continuation of RAAS where benefit outweighs risk.
Medicine summary: RAAS blockers (ACEi/ARB) & SGLT2 inhibitors form the backbone of modern DKD therapy. Finerenone & GLP-1 RAs are add-on options in selected patients. Dose adjustments by eGFR, age, and comorbid conditions are essential.
Non-pharmacologic care, diet — क्या recommended और क्या avoid करें।
Recommended
- Balanced diet: vegetables, controlled complex carbohydrates, adequate but not excessive protein as per renal dietitian (non-dialysis CKD ~0.6–0.8 g/kg/day if appropriate).
- Low-sodium cooking: aim <2 g sodium/day (~5 g salt).
- Whole foods, avoid processed items high in phosphate additives.
- Maintain adequate calories to prevent protein-energy wasting.
- Vaccinations: annual influenza, pneumococcal as per guidelines; hepatitis B for select CKD/dialysis patients.
Avoid / Limit
- NSAIDs & some herbal medications (nephrotoxic) — avoid unless clinician approves.
- Unsupervised high-protein supplements.
- Excess dietary potassium or phosphate only if labs show derangement; do not indiscriminately restrict fruits/vegetables without lab evidence.
Hindi note: "जितना जरूरी प्रोटीन, उतना ही लें; ज्यादा प्रोटीन से किडनी पे लोड बढ़ता है — पर मलनौरीश होने से भी बचाना है. इसलिए डायटीशियन का प्लान ज़रूर फॉलो"
Monitoring & follow-up (practical schedule)
- ACR & eGFR: annually if normal; 3–6 monthly if ACR 30–300; monthly/quarterly if ACR >300 or falling eGFR.
- Serum creatinine & K+: baseline and 1–2 weeks after RAAS initiation/dose change; then per CKD stage.
- HbA1c every 3 months until stable, then per control.
- Home BP logs and medication adherence check at each visit.
Patient education: "Sick-day rules" — stop SGLT2s & metformin during acute vomiting/diarrhea/dehydration and seek medical advice.
Complications & management highlights
- ESRD: dialysis (HD/PD) or renal transplant — early planning improves outcomes.
- Cardiovascular disease: leading cause of mortality — aggressive risk reduction needed.
- CKD-MBD: monitor Ca/PO4/PTH and treat with binders/vitamin D analogs as needed.
- Anemia: iron repletion and ESA per nephrology guidance.
- Infections: increased risk — early diagnosis and vaccination help.
When to refer — nephrology & RRT planning
- Refer early if: eGFR <30 mL/min/1.73m², rapidly declining eGFR, refractory hyperkalemia/acidosis, or planning RRT.
- Start access planning (AV fistula) well before expected dialysis need; avoid urgent catheter starts where possible.
- Consider transplant evaluation in suitable candidates early — better long-term outcomes.
Special populations
Pregnancy
Preconception counseling is essential. ACEi/ARB contraindicated — switch prior to conception. Multidisciplinary care (OB/Gyn + nephrology + endocrinology) required.
Elderly
Individualize HbA1c and BP targets to minimize hypoglycemia and falls; review polypharmacy and goals of care.
Children & adolescents
Type 1 diabetes: start screening 5 years after diagnosis or at puberty; collaborate with pediatric nephrology.
Clinic checklist (MBBS/MD students & junior doctors)
- History: duration of diabetes, meds (ACEi/ARB/SGLT2/NSAIDs/herbs), UTI history, family kidney disease, symptoms of uremia.
- Exam: BP both arms, edema, signs of fluid overload, retinopathy screen, neuropathy exam (see Diabetic Neuropathy). https://www.mahfoozmedicalhealth.com/2025/08/diabetic-neuropathy-comprehensive-guide.html
- Investigations: ACR x2 of 3, eGFR, electrolytes, HbA1c, lipid profile, CBC, urine microscopy.
- Initial Rx: start ACEi/ARB for albuminuria unless contraindicated; counsel about K+ monitoring; consider SGLT2 if indicated.
Internal links & related posts (automatic linking where terms appear)
FAQs — (Hindi + English brief)
Q: क्या diabetic nephropathy reverse हो सकती है?
A: Early albuminuria regression मुमकिन है with tight glycemic & BP control, RAAS blockade and SGLT2 therapy. लेकिन established glomerulosclerosis often irreversible — aim progression को slow/stop करना है.
Q: ACEi start करने के बाद creatinine अगर बढ़ता है तो क्या करें?
A: ≤30% rise from baseline acceptable — monitor. आगर rise >30% ya hyperkalemia uncontrolled हो तो review/stop and consult nephrology.
Q: SGLT2 को कब stop करना चाहिए?
A: Acute illness, dehydration, vomiting/diarrhea, before major surgery — temporarily stop. Resume after recovery and medical review.
Key takeaways — क्लिनिकल सारांश
- Annual ACR & eGFR screening indispensable in diabetes.
- RAAS blockade (ACEi/ARB) + SGLT2 inhibitors are central to current DKD management.
- Individualize glycemic/BP targets; monitor and adjust drug doses by age & eGFR.
- Refer early to nephrology for progressive disease and RRT planning.