The Kidney in Type I Diabetes

Abstract

Diabetic kidney disease (DKD) is a serious complication of type 1 diabetes (T1D) and represents a major cause of end stage renal disease (ESRD) and cardiovascular morbidity and mortality. DKD occurs due to interactions between several factors, including hyperglycemia, dyslipidemia, hypertension, oxidative stress, advanced glycated end products, and genetic factors, which induce progressive functional and structural changes in the kidney. Clinically, DKD is characterized by increasing albuminuria, progressive decline in glomerular filtration rate, and elevated blood pressure, which without any treatment progress towards ESRD. Advanced stages of DKD are rare among children and adolescents with T1D, whereas early stages, such as hyperfiltration and moderately increased albuminuria, can be common. Several risk factors contribute to the development of DKD, the main being hyperglycemia, high blood pressure, dyslipidemia, diabetes duration, age at diagnosis, female gender, and puberty, along with genetic and environmental factors. Albuminuria, formerly known as microalbuminuria, is considered the earliest clinical manifestation of DKD and is the basis for screening for this complication. Screening for DKD is recommended starting at age 10-12 years and repeated annually. During adolescence, the primary focus of management the risk of DKD is improvement in glycemic control. Targeting additional risk factors, such as hypertension, dyslipidemia, and obesity, is also recommended. When persistent albuminuria is detected, treatment with angiotensin-converting enzyme inhibitors is indicated. There is still a need for new biomarkers to facilitate early detection of subclinical stages of DKD and to support the implementation of intervention strategies, to ultimately reduce the burden of DKD.