Prognosis

DKD can progress to end-stage renal disease (ESRD) requiring dialysis or kidney transplantation and is the leading cause of ESRD in the US.[1]​ As is observed in other forms of chronic kidney disease (CKD), the degree of albuminuria is a strong predictor of risk of progression, with non-albuminuric DKD having a better prognosis.[36]​ Several other clinical characteristics have been described that are associated with higher risk of progression of DKD, including rate of estimated glomerular filtration rate (eGFR) decline, systolic blood pressure, HbA1c, duration of diabetes, serum uric acid, concomitant microvascular complications, and positive family history.[36]

Among patients with diabetes, those with kidney disease are consistently observed to have substantially elevated mortality rates. Much of this mortality is due to cardiovascular disease (CVD), although non-CV mortality is also increased.[222]​ While DKD may be in part a marker of systemic end-organ damage of diabetes, abundant evidence suggests that it may contribute to the pathogenesis of CVD.[222] Albuminuria and eGFR are independently and additively associated with increased risks of CVD events, CVD mortality, and all-cause mortality.[46]​ Both diabetes and CKD have been observed to have incidence rates of CVD events similar to patients with established coronary heart disease, leading to recommendations that patients with diabetes, CKD, or both should be treated for prevention of CVD as if they had already experienced such an event.[222] In both type 1 and type 2 diabetes, evidence suggests that increased risks of mortality and CVD are limited to patients who have evidence of DKD, and that patients with normal levels of albuminuria and eGFR have risks similar to the general nondiabetic population.[222] These observations suggest that treatment strategies focused on mitigating the high CVD risk of patients with DKD should be a high priority for improving diabetes outcomes.[222] 

Morbidity and mortality can be avoided or delayed with intensive treatment of hyperglycemia, hypertension, and dyslipidemia, blockade of the renin-angiotensin system, use of agents with proven cardiorenal protective benefit (e.g., sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists, and, to some extent, glucagon-like peptide-1 receptor agonists), careful attention to diet, and avoidance of nephrotoxic agents.[34]​ Indeed, a decline in the incidence of DKD over the past 30 years and improved patient prognosis are considered to be attributable to improved diabetes care.[34]

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