Persistent hyperglycaemia is linked with increased likelihood of developing nephro-pathy. Normalization of the blood glucose slows the rate of deterioration of renal function. This may be difficult to achieve without hypoglycaemia in patients with impaired renal function who should perform frequent finger-prick blood glucose testing. Most of these patients will end up on insulin although 50 per cent of people with diabetes who develop end-stage renal failure have Type 2 diabetes.
Tight control of hypertension slows deterioration of renal function in nephropaths. This means treating people whose blood pressure would not normally fall into the treatment range for non-diabetic people. In patients with known diabetic kidney disease the aim is to keep the blood pressure below 125/75 but be careful to avoid dizziness and falls in patients with severe postural hypotension due to autonomic neuropathy.
Treating microalbuminuria (see p. 54)
There is evidence that ACE inhibitors slow the progression of diabetic nephropathy if initiated when persistent microalbuminuria is detected. Test for microalbumin: creatinine ratio annually in patients without dipstick proteinuria. If the ratio is raised in two of three samples collected consecutively within one month, prescribe an ACE inhibitor e.g. Ramipril.
A reduction in sodium chloride intake may help control hypertension and reduce fluid retention.
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