Role of glycemic control and protein restriction in clinical management of diabetic kidney disease.
OBJECTIVE
To assess the role of control of blood glucose levels and restriction of dietary protein in the management of diabetic nephropathy.


METHODS
We summarize the results of pertinent published studies of glycemic control and modification of protein intake to provide information about strategies that potentially could benefit patients with diabetes and renal dysfunction.


RESULTS
Considerable evidence is available to support the contention that improved glycemic control may have beneficial effects on the development and progression of diabetic renal disease. Maximal benefits of improved glycemia occur when instituted before the onset of macroalbuminuria. Once overt diabetic nephropathy is established, improved glycemic control may not be beneficial. Current evidence indicates that a glycosylated hemoglobin level of less than 8.1% should be the glycemic goal. At this level, the risk of developing micro-albuminuria is substantially reduced, and the risk of hypoglycemia is minimized. Most studies have been conducted in type I diabetes, and the results have been extrapolated to type II diabetes. Whether improved glycemic control will be equally beneficial in the nephropathy of type II diabetes has yet to be determined. Although some scientific evidence supports dietary protein restriction in patients with diabetic nephropathy, the extent of restriction needed for optimal benefits and minimal side effects remains to be determined. On the basis of current information, patients with both types of diabetes who have evidence of nephropathy should have protein limited to the recommended dietary allowance for adults (0.8 g/kg of body weight per day or approximately 10% of total daily caloric intake), and protein should be derived primarily from vegetable and lean animal sources.


CONCLUSIONS
End-stage renal disease is not inevitable in patients with diabetic nephropathy. Normalization of glucose levels and modification of protein intake can favorably influence the course of diabetes-related kidney disease.
Mudaliar
S R
SR
Department of Medicine, University of California, San Diego, and the Veterans Affairs Medical Center, San Diego, California 92161, USA.
Henry
R R
RR