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
The presence of microvascular disease in patients with T2D and DKD is less predictable.12 In T2D patients who do not have retinopathy, consider causes of CKD other than DKD. Features suggesting that the cause of CKD is an underlying condition other than diabetes are rapidly increasing albuminuria or decreasing eGFR; urinary sediment comprising red blood cells or white blood cells; and nephrotic syndrome.6
As the prevalence of diabetes increases, it has become more common to diagnose DKD by eGFR without albuminuria—underscoring the importance of routine monitoring of eGFR in patients with diabetes.6
Sources of expert guidance. The Chronic Kidney Disease Epidemiology Collaboration equation23 is preferred for calculating eGFR from serum creatinine: An eGFR < 60 mL/min/1.73 m2 is considered abnormal.3,12 At these rates, the prevalence of complications related to CKD rises and screening for complications becomes necessary.
A more comprehensive classification of the stages of CKD, incorporating albuminuria and progression of CKD, has been recommended by Kidney Disease: Improving Global Outcomes (KDIGO).7 Because eGFR and excretion of albumin vary, abnormal test results need to be verified over time to stage the degree of CKD.3,12 Kidney damage often manifests as albuminuria, but also as hematuria, other types of abnormal urinary sediment, radiographic abnormalities, and other abnormal presentations.
Management
Nutritional factors
Excessive protein intake has been shown to increase albuminuria, worsen renal function, and increase CVD mortality in DKD.24-26 Therefore, daily dietary protein intake of 0.8 g/kg body weight is recommended for patients who are not on dialysis.3 Patients on dialysis might require higher protein intake to preserve muscle mass caused by protein-energy wasting, which is common in dialysis patients.6
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