Tactics to prevent or slow progression of CKD in patients with diabetes
Annual screening of urinary parameters, ongoing clinical vigilance, and proper medical therapy can help to keep declining renal function at bay.
PRACTICE RECOMMENDATIONS
› Screen patients with diabetes annually for diabetic kidney disease with measurement of urinary albumin and the estimated glomerular filtration rate. B
› Optimize blood glucose and blood pressure control in patients with diabetes to prevent or delay progression to diabetic kidney disease. A
› Treat hypertensive patients with diabetes and stages 1 to 4 chronic kidney disease with an angiotensin-converting enzyme inhibitor or angiotensin II-receptor blocker as a first-line antihypertensive, absent contraindications. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Recommended DKD screening protocol
In all cases of T2D, in cases of T1D of ≥ 5 years’ duration, and in patients with diabetes and comorbid hypertension, perform annual screening for albuminuria, an elevated creatinine level, and a decline in eGFR.
To confirm the diagnosis of DKD, at least 2 of 3 urine specimens must demonstrate an elevated urinary albumin:creatinine ratio (UACR) over a 3- to 6-month period.21 Apart from renal damage, exercise within 24 hours before specimen collection, infection, fever, congestive heart failure, hyperglycemia, menstruation, and hypertension can elevate the UACR.6
Levels of the UACR are established as follows22:
- Normal UACR is defined as < 30 milligrams of albumin per gram of creatinine (expressed as “mg/g”).
- Increased urinary albumin excretion is defined as ≥ 30 mg/g.
- Moderately increased albuminuria, a predictor of potential nephropathy, is the excretion of 30 to 300 mg/g.
- Severely increased albuminuria is excretion > 300 mg/g; it is often followed by a gradual decline in eGFR that, without treatment, eventually leads to ESRD.
The rate of decline in eGFR once albuminuria is severely increased is equivalent in T1D and T2D.12 Without intervention, the time from severely increased albuminuria to ESRD in T1D and T2D averages approximately 6 or 7 years.
Clinical features
DKD is typically a clinical diagnosis seen in patients with longstanding diabetes, albuminuria, retinopathy, or a reduced eGFR in the absence of another primary cause of kidney damage. In patients with T1D and DKD, signs of retinopathy and neuropathy are almost always present at diagnosis, unless a diagnosis is made early in the course of diabetes.12 Therefore, the presence of retinopathy suggests that diabetes is the likely cause of CKD.
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