Managing Proteinuria in Diabetic Kidney Disease: When to Start Low-Protein Diet?

Q: Managing Proteinuria in Diabetic Kidney Disease: When to Start Low-Protein Diet?

According to your inquiry regarding the classification of UACR： UACR < 30 mg/g is considered normal range; UACR 30-300 mg/g is classified as microalbuminuria; and UACR > 300 mg/g is classified as macroalbuminuria. <br>Since you only mentioned "UACR results < 300," it is unclear w

Proteinuria and Diabetic Kidney Disease (DKD)

Hello, doctor.
I have been diagnosed with diabetes for about ten years and have consistently had microalbuminuria.
My eGFR has been around 105 ± 10 for several years.
I had a UACR > 300 tested before surgery at National Taiwan University Hospital last year and again this year, while several other UACR tests in between showed results < 300.
I anxiously consulted a nephrologist, but the doctor did not provide any treatment and just advised to continue monitoring.
My family medicine physician had no specific comments, only suggesting that if I was very concerned, I should see a nephrologist.
Over the past year, my HbA1c has been around 5.8-6.1, and my blood pressure is approximately 120/70 while taking one tablet of Amlodipine daily.
I would like to ask whether I should start a low-protein diet.
I have seen recommendations to begin this at stage 3, but I have also found that DKD patients should start a low-protein diet upon diagnosis.
I am unsure what would be appropriate and would appreciate your guidance.
Thank you.

Gladys, 40~49 year old female. Ask Date: 2022/02/09

Dr. Wu Jiyu reply Internal Medicine

According to your inquiry regarding the classification of UACR: UACR < 30 mg/g is considered normal range; UACR 30-300 mg/g is classified as microalbuminuria; and UACR > 300 mg/g is classified as macroalbuminuria.
Since you only mentioned "UACR results < 300," it is unclear whether it is UACR < 30 mg/g.
Regardless, it is essential to manage the three highs (hypertension, hyperglycemia, and hyperlipidemia) through medication, diet, and exercise.
Currently, there is a glucose-lowering medication known as sodium-glucose cotransporter-2 (SGLT2) inhibitors, which has shown effectiveness in controlling UACR levels above 200 mg/g.
Please discuss your suitability for this treatment with your primary physician.
Thank you for your inquiry.
The Nephrology Department at Changhua Hospital cares about your health.

Reply Date: 2022/02/09

More Info

Managing proteinuria in diabetic kidney disease (DKD) is a critical aspect of preserving kidney function and overall health. Your situation, characterized by a long-standing history of diabetes and fluctuating urine albumin-to-creatinine ratio (UACR), raises important considerations regarding dietary management, particularly the initiation of a low-protein diet.

Understanding Proteinuria and DKD
Proteinuria, especially microalbuminuria, is often one of the first signs of kidney damage in individuals with diabetes. The presence of protein in the urine indicates that the kidneys are not filtering blood properly, which can lead to further kidney damage if not managed appropriately. The UACR values you mentioned, with instances exceeding 300 mg/g, suggest that your kidneys are under stress, and this should be taken seriously.

When to Start a Low-Protein Diet
The timing of initiating a low-protein diet in the context of DKD is a topic of some debate among healthcare professionals. Traditionally, it has been recommended to start a low-protein diet when kidney function declines to stage 3 chronic kidney disease (CKD), which corresponds to an estimated glomerular filtration rate (eGFR) of 30-59 mL/min. However, recent studies suggest that early intervention may be beneficial, even before reaching this stage, especially in patients with diabetes who exhibit signs of kidney damage, such as proteinuria.

Given your eGFR of approximately 105 mL/min, you are currently in a stage where kidney function is considered normal. However, the presence of proteinuria indicates that there is underlying kidney damage. Therefore, while some guidelines suggest waiting until stage 3 CKD to initiate a low-protein diet, others advocate for starting it earlier in the presence of significant proteinuria, particularly in diabetic patients.

Recommended Protein Intake
For individuals with DKD, a low-protein diet typically consists of 0.6 to 0.8 grams of protein per kilogram of body weight per day. This reduction in protein intake can help decrease the workload on the kidneys and slow the progression of kidney disease. However, it is essential to ensure that the diet remains nutritionally adequate, providing sufficient calories and essential nutrients.

Other Considerations
1. Blood Sugar Control: Maintaining optimal blood glucose levels is crucial in managing DKD. Your HbA1c levels of 5.8-6.1% are commendable and indicate good glycemic control, which is vital in preventing further kidney damage.

2. Blood Pressure Management: Your blood pressure readings of 120/70 mmHg are within the normal range, which is beneficial for kidney health. Continue monitoring your blood pressure and maintain it below 130/80 mmHg.

3. Regular Monitoring: Regular follow-ups with your healthcare provider, including nephrologists, are essential. They can help monitor your kidney function and adjust dietary recommendations as needed.

4. Dietary Consultation: Consulting with a registered dietitian who specializes in kidney disease can provide personalized dietary recommendations. They can help you navigate food choices, especially when eating out, to ensure you adhere to a low-protein diet while still enjoying your meals.

5. Medications: Discuss with your healthcare provider the potential benefits of medications such as SGLT2 inhibitors, which have shown promise in reducing proteinuria and protecting kidney function in diabetic patients.

Conclusion
In summary, while traditional guidelines suggest starting a low-protein diet at stage 3 CKD, the presence of proteinuria in your case warrants consideration for earlier dietary intervention. A low-protein diet, combined with excellent blood sugar and blood pressure control, can help slow the progression of kidney disease. Regular monitoring and consultation with healthcare professionals will be key in managing your condition effectively. Always discuss any dietary changes with your healthcare provider to ensure they align with your overall health strategy.

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