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Type 2 Diabetes Management Guidelines

Management of diabetic kidney disease

  • Red flags for alternative causes of renal dysfunction in patients with diabetes
  • Short duration of diabetes e.g. < 5 years
  • Young patients e.g. < 30 years of age
  • Persistent decline in eGFR > 1 mL/min per month or > 10 mL/min per year (NB: eGFR is hydration dependent)
  • No evidence of diabetic retinopathy
  • Family history of renal disease
  • Overt features of alternative cause e.g. connective tissue disease, recurrent UTIs, hypertension, casts on MSU
  • Persistent albuminuria is defined by urinary albumin:creatinine ratios (ACR) in the following categories:
    • A1 - 'Normal to mildly increased' - ACR < 3 mg/mmol
    • A2 - 'Moderately increased or microalbuminuria' - ACR 3 - 30 mg/mmol
    • A3 - 'Severely increased or macroalbuminuria' - ACR > 30 mg/mmol
  • Two positive samples are required for the first diagnosis of persistent albuminuria to exclude falsely raised ratios due to:
  • UTI
  • Intercurrent illness
  • Vigorous physical activity
  • Haematuria
  • Significant hyperglycaemia
  • GFR categories are defined by the following categories:
    • G1 -   Normal or high - > 90 mL/min
    • G2 -   Mildly decreased - 60 - 89 mL/min
    • G3a - Mildly to moderately decreased - 45 - 59 mL/min
    • G3b - Moderately to severely decreased - 30 - 44 mL/min
    • G4 -   Severely decreased - 15 - 29 mL/min
    • G5 -   Renal failure
  1. Renin/angiotensin/aldosterone (RAA) blockade +  manage hypertension aggressively aiming for target blood pressure < 130/80 mmHg
    • Start ACEi or ARB regardless of blood pressure if no concerns over hypotension and no contraindications (do not use in combination without specialist opinion and do not use either if on Entresto)
      • In women of childbearing age ensure effective contraception + not pregnant before starting
      • Repeat eGFR and potassium 2 - 4 weeks after starting
        • If > 30% reduction in eGFR reduce or stop the ACEi/ARB and consider renal artery stenosis
        • If potassium > 6 mmol/L reduce or stop the ACEi/ARB and consider seeking dietitian and/or renal advice
    • Maximise dose of ACEi/ARB before the addition of another agent (repeat eGFR + potassium 2-4 weeks after any dose increase)
    • If blood pressure not to target add a calcium channel blocker or thiazide diuretic (chlorthalidone is the preferred thiazide as it is long-acting)
    • In those with refractory hypertension consider adding spironolactone or eplenerone (beware increased risk of hyperkalaemia), OR an alpha blocker OR a beta-blocker
    • Consider advising patients with diabetic kidney disease to purchase a home blood pressure monitor (not funded) given the importance of BP control

2. Optimise glycaemic control

3. Optimise cardiovascular risk

4. Monitor and review regularly