•Research suggests diabetic kidney disease (DKD) is a major complication of diabetes, affecting kidney function and potentially leading to kidney failure.

•It seems likely that in India, DKD is increasingly common due to high diabetes prevalence, with studies indicating a significant burden.

•The evidence leans toward managing DKD through blood sugar and blood pressure control, medications like ACE inhibitors, and lifestyle changes.

•There is ongoing research into new treatments, such as SGLT2 inhibitors, which may help slow DKD progression, particularly relevant for Indian patients.

 

Diabetic kidney disease, or diabetic nephropathy, happens when high blood sugar damages the kidneys’ small blood vessels, affecting their ability to filter waste. This can lead to protein in the urine and, over time, kidney failure if not managed.

 

Early stages often show no symptoms, but as it progresses, you might notice swelling in your legs or feet, tiredness, nausea, or changes in urine. Doctors diagnose it with urine tests for albumin, blood tests for kidney function, and sometimes imaging like ultrasounds.

 

Managing DKD involves controlling blood sugar and blood pressure, using medications like ACE inhibitors or ARBs, and following a diet low in salt and sugar. Regular check-ups are crucial, and for Indian patients, incorporating local foods like whole grains and lean proteins can help.

 

In India, DKD is a growing concern due to high diabetes rates. The Indian Council of Medical Research (ICMR) provides guidelines, and recent studies highlight the need for early detection and prevention, especially given cultural and dietary factors.

 

Survey Note: Comprehensive Guide on Diabetic Kidney Disease from an Indian Perspective

 

This detailed guide aims to provide patients with a thorough understanding of diabetic kidney disease (DKD), also known as diabetic nephropathy, with a focus on the Indian context. It integrates the latest research, recommendations, and practical advice, ensuring relevance for patients in India.

 

Diabetic kidney disease is a chronic complication of diabetes, affecting the kidneys by damaging the small blood vessels responsible for filtering waste from the blood. This damage can lead to albuminuria (protein in the urine) and a progressive decline in kidney function, potentially resulting in kidney failure. It is a significant concern for both type 1 and type 2 diabetes patients, with global studies indicating it affects 20–50% of diabetic individuals over time.

 

In the Indian context, the rising prevalence of diabetes, estimated at over 74 million people as of recent reports, underscores the importance of addressing DKD. The disease’s impact is particularly notable given India’s diverse population, varying healthcare access, and cultural dietary practices.

 

Early stages of DKD are often asymptomatic, making regular screening essential. As the disease progresses, patients may experience:

 

•Swelling in the legs, feet, or hands due to fluid retention

•Persistent tiredness or weakness

•Nausea, vomiting, or loss of appetite

•Itchy skin

•Changes in urine output, such as increased frequency or darker color

 

Diagnosis typically involves several tests, as outlined in the ICMR Guidelines for Management of Type 2 Diabetes 2018 (ICMR Guidelines for Management of Type 2 Diabetes 2018). These include:

 

•Urine microscopy for casts, pus cells, and red blood cells

•Blood tests for urea and serum creatinine to calculate estimated glomerular filtration rate (eGFR)

•Microalbuminuria testing to detect early kidney damage

•Ultrasound (USG) abdomen, if feasible, for structural assessment

•Serum sodium and potassium levels to monitor electrolyte balance

 

The ICMR guidelines emphasize the importance of differentiating diabetic from non-diabetic causes of kidney disease, with an algorithm provided in Figure 8.1 for evaluating proteinuria.

 

India faces a significant burden of DKD, driven by the country’s high diabetes prevalence. A 2023 study highlighted that India is the second most affected country globally for chronic kidney disease, with 115.1 million cases, and DKD is a leading cause (The burden of diabetic nephropathy in India: Need for prevention). Recent research, such as a 2024 study on a multi-ethnic Asian population, found 56.7% of type 2 diabetes patients had DKD, suggesting similar trends in India due to comparable demographics.

 

The economic and societal burden is high, particularly in low- and middle-income settings, where late diagnosis often leads to end-stage renal disease (ESRD) requiring dialysis, which can be unaffordable. Early identification and prevention are critical, as noted in studies emphasizing the need for increased awareness and screening.

 

Several risk factors increase the likelihood of developing DKD, many of which are modifiable:

 

•Poor blood sugar control, leading to prolonged hyperglycemia

•High blood pressure, which exacerbates kidney damage

•High cholesterol levels, contributing to vascular complications

•Smoking, which impairs blood flow to the kidneys

•Family history of kidney disease, indicating genetic predisposition

•Obesity, linked to insulin resistance and increased disease risk

 

Managing these risks involves maintaining tight glycemic control, controlling hypertension with medications like ACE inhibitors or ARBs, quitting smoking, and achieving a healthy weight through diet and exercise. The ICMR guidelines recommend screening for microalbuminuria five years after type 1 diabetes diagnosis and at diagnosis for type 2, highlighting the need for early intervention.

 

Recent global and Indian research has provided new insights into DKD management. Internationally, the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease) updates recommendations, emphasizing SGLT2 inhibitors for slowing DKD progression, based on trials like the CREDENCE study. These findings are relevant for Indian patients, given the high diabetes burden.

 

In India, studies like a 2024 publication on DKD prevalence in multi-ethnic Asian countries (Prevalence of diabetic kidney disease and the associated factors among patients with type 2 diabetes in a multi-ethnic Asian country | Scientific) highlight risk factors such as longer diabetes duration, hypertension, and poor HbA1c control. Another study from South India assessed non-diabetic kidney disease in diabetic patients, finding that some cases are not DKD-related, underscoring the need for accurate diagnosis (Non-diabetic Kidney Disease in Diabetic Population: A Single-Center Study From South India).

 

Management of DKD requires a multifaceted approach, aligning with both ICMR and international guidelines:

 

1.Blood Sugar Control: Maintaining HbA1c levels within target ranges (typically <7%) to prevent further kidney damage, using medications like metformin and insulin as needed.

2.Blood Pressure Control: The ICMR guidelines recommend ACE inhibitors or ARBs as first-line treatments for hypertension in nephropathy, never combining both due to risk of hyperkalemia. Alternatives include calcium channel blockers, diuretics, and selective beta blockers for patients with a history of acute coronary syndrome.

3.Cholesterol Management: Statins are recommended to manage dyslipidemia, reducing cardiovascular risk, which is high in DKD patients.

4.Dietary Management: The ICMR guidelines suggest protein intake of 0.6 g/kg ideal body weight plus 24-hour urinary protein loss (not <40 g/day), sodium restriction to 1000–2000 mg/day, and potassium restriction based on blood levels and diuretic use. For Indian patients, incorporating local foods like moong dal (low in potassium and phosphorus) and ridge gourd (diuretic properties) is beneficial (Indian Diet Chart for Diabetic and Kidney Patient).

5.Regular Monitoring: Regular check-ups to monitor eGFR, albuminuria, and other parameters, with referral to a nephrologist for conditions like serum creatinine >1.5 mg%, eGFR <60 ml/min, or nephrotic range proteinuria.

 

Newer treatments, such as GLP-1 receptor agonists (e.g., semaglutide), are being studied for their renal protective effects, with trials like FLOW showing promise, potentially influencing future guidelines (Recent Advances in the Management of Diabetic Kidney Disease: Slowing Progression).

 

Given India’s diverse culinary traditions, dietary management is crucial. Patients should:

 

•Consume whole grains like atta (whole wheat) rotis, limiting to 2–3 per day, and avoid refined flour (maida) (Indian Diet Chart For Diabetic And Kidney Patient).

•Include low-potassium vegetables like ridge gourd and fruits like apples, ensuring adequate hydration as per doctor’s advice.

•Limit salt intake, avoiding high-sodium processed foods, and use spices like turmeric for flavor instead.

•Opt for lean proteins like fish and plant-based options like lentils, while moderating beans due to potential high phosphorus and potassium content.

•Engage in moderate exercise, such as walking 30 minutes daily, tailored to individual fitness levels, considering cultural practices like yoga.

 

•Persistent swelling, especially in the legs or feet

•Unexplained weight loss or fatigue

•Changes in urine color, frequency, or volume

•Symptoms like nausea, vomiting, or difficulty breathing

•Signs of confusion or disorientation, which may indicate advanced kidney dysfunction

 

The ICMR guidelines specify referral to a nephrologist for severe conditions, ensuring timely intervention to prevent progression to ESRD.

 

•The Indian Diabetes Association for diabetes management resources

•The Indian Society of Nephrology for kidney disease information and support

•Local hospitals and clinics, such as those under the National Health Mission, offering diabetes and kidney care services (Diabetes Mellitus | National Health Portal Of India)

•Community health programs, with the government aiming to place 75 million people with hypertension or diabetes on standard care by 2025 (India: 75 million people with hypertension or diabetes on standard care by 2025)

 

Table: Summary of ICMR Recommendations for Diabetic Nephropathy

 

Aspect Details Investigations Urine microscopy, blood urea, serum creatinine, eGFR, microalbuminuria, USG abdomen, serum sodium/potassium Hypertension TreatmentACE inhibitors or ARBs (first-line), alternatives include calcium channel blockers, diuretics, beta blockersDietary Modifications Protein: 0.6 g/kg + 24-hour urinary protein loss; Sodium: 1000–2000 mg/day; Potassium: restrict based on levels Referral Criteria Severe hypertension, potassium >5.5 meq/L, nephrotic proteinuria, eGFR <60 ml/min, etc. This guide ensures patients have a comprehensive understanding of DKD, tailored to the Indian context, with actionable steps for management and support.

 

•ICMR Guidelines for Management of Type 2 Diabetes 2018

•The burden of diabetic nephropathy in India: Need for prevention

•KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease

•Prevalence of diabetic kidney disease and the associated factors among patients with type 2 diabetes in a multi-ethnic Asian country | Scientific