Table 1.
Pharmaceutical interventions in the management of diabetic kidney disease.
| Drug Class | Impact on Proteinuria |
Acute Effects on Kidney Function |
Long-Term Impact on Kidney Function |
Mechanisms Leading to Reduced Proteinuria | Mechanisms of Renal Protection |
|---|---|---|---|---|---|
| ACE inhibitors | Reduce proteinuria | Reduce GFR | Renoprotective | - Reduce glomerular hypertension via efferent arteriolar vasodilation - Improved metabolic control attenuates structural glomerular changes - Improved tubular protein re-uptake? |
- Reducing proteinuria leads to attenuated tubulointerstitial disease - Blocking Ang II/aldosterone-mediated inflammation, tubular apoptosis and fibrosis |
| ARBs | Reduce proteinuria | Reduce GFR | Renoprotective | Reduce glomerular hypertension via efferent arteriolar vasodilation | - Reducing proteinuria leads to attenuated tubulointerstitial disease - Blocking Ang II/aldosterone-mediated inflammation, tubular apoptosis and fibrosis |
| SGLT2 inhibitors | Reduce proteinuria | Reduce GFR | Renoprotective | Immediate reduction in glomerular hypertension via restoration of tubulo-glomerular feedback (TGF) | - Improved metabolic control attenuates structural glomerular injury - Reducing proteinuria leads to attenuated tubulointerstitial disease - Possible additional anti-fibrotic properties |
| DPP4 antagonists | Reduce proteinuria | None | Probably no impact | Restoration of metabolic derangements leading to gradual reduction in glomerular hypertension via restoration of TGF with afferent arteriolar vasoconstriction afferent arteriolar vasoconstriction | - Improved metabolic control may attenuate structural glomerular injury - Reducing proteinuria may lead to attenuated tubulointerstitial disease |
| GLP1 analogues | Reduce proteinuria | None Mildly reduced GFR by 12 weeks |
Currently unknown | Restoration of metabolic derangements leading to gradual reduction in glomerular hypertension via restoration of TGF with afferent arteriolar vasoconstriction afferent arteriolar vasoconstriction | - Improved metabolic control may attenuate structural glomerular injury - Reducing proteinuria may lead to attenuated tubulointerstitial disease |