What to do about severe proteinuria in diabetics on ACE

[quickfeet]

Curious what you do in diabetics with relatively good control A1c under 7.5, on ACE-i, without marked decrease in eGFR who consistently have ACR's that are really high.

(Other than aggressive BP control)

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[rokshana]

Curious what you do in diabetics with relatively good control A1c under 7.5, on ACE-i, without marked decrease in eGFR who consistently have ACR's that are really high.

(Other than aggressive BP control)

send them to nephrology...there could be another reason that is not necessarily diabetes related (though eventually with long standing diabetes, there will be proteinuria).

 

[ASM student]

Still a student here but from I know ACE-i are only effective in preventing the progression from microalbuminuria to protienuria but once protienuria develops there's not much to be done, that's why a lot of care is directed to the screening for micro albuminuria.

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[DarkLordofSith]

Use of non-dihydropyridine calcium channel blockers has been shown by numerous studies to slow proteinuria in diabetics and recommendations all state you should use them, but internists just don't feel comfortable starting them for some reason.

So if you all want to help your diabetic patients with proteinuria, stop using amlodipine/nifedipine and start using diltiazem.

Edit: Don't use ACEi/ARB despite what NKF guidelines say. See below.

NKF KDOQI Guidelines

 

[ANCAdoc]

Refer to nephrology for further evaluation.

Medications such as non-dihydropyridine CCBs and spironolactone can reduce proteinuria, used after ACEi or ARB is maximized. Do NOT recommend combined ACEi/ARB - trials have been negative and only support increased risks such as AKI, hyperkalemia, etc. Low salt diet, BP control, weight loss. May need treatment for unique renal pathology - see below.

It is possible they have another cause for proteinuria other than DMII. Perhaps they have nephrotic range proteinuria or true nephrotic syndrome (even with normal eGFR). If they've had longstanding DMII which has been uncontrolled for many years, only recently controlled, then I would expect rather significant proteinuria. If proteinuria cannot be explained by poorly controlled DMII then other causes are at play. Perhaps secondary FSGS due to obesity, solitary kidney or primary FSGS. Or Membranous Nephropathy (will have a negative serologic workup and only found on kidney biopsy). Or paraproteinemias (myeloma, monoclonal gammopathy of renal significance, fibrillary GN, etc). Really a laundry list of diagnoses to consider, which a nephrologist would evaluate in the right clinical context.

 

[smartparts]

Refer to nephrology for further evaluation.

Medications such as non-dihydropyridine CCBs and spironolactone can reduce proteinuria, used after ACEi or ARB is maximized. Do NOT recommend combined ACEi/ARB - trials have been negative and only support increased risks such as AKI, hyperkalemia, etc. Low salt diet, BP control, weight loss. May need treatment for unique renal pathology - see below.

agreed. citation: VA-NEPHRON D trial

 

[DarkLordofSith]

agreed. citation: VA-NEPHRON D trial

Thank you, that's really good to know. I personally haven't used combination ACE/ARB but always found those NKF guidelines intriguing. I guess they need to be updated.

 

[PlutoBoy]

Use of non-dihydropyridine calcium channel blockers has been shown by numerous studies to slow proteinuria in diabetics and recommendations all state you should use them, but internists just don't feel comfortable starting them for some reason.

So if you all want to help your diabetic patients with proteinuria, stop using amlodipine/nifedipine and start using diltiazem.

Edit: Don't use ACEi/ARB despite what NKF guidelines say. See below.

NKF KDOQI Guidelines

I'm sorry but did I didn't see that in the guidelines. I did see this:

Numerous studies have shown that dihydropyridine calcium channel blockers are less efficacious than ACE inhibitors, ARBs, and nondihydropyridine calcium channel blockers in reducing albuminuria in DKD.

Did I miss something?

 

[Crayola227]

I just want to write a note that says

"Pt was given ___ per nephro's recs"

I know that's wrong. But it makes me happy.

I would settle for a ppt presentation too. but can't read big blocks text no no no more

 

[DarkLordofSith]

Perhaps I should've been more clear and how I was saying it. We see diabetic patients with proteinuria on amlodipine and nifedipine all the time. I think we should start thinking about using NDHP CCB more readily in their place as long as there isn't a contraindication.