Information
Diabetes kidney disease or nephropathy is defined as albuminuria and progressive reduction in eGFR in the setting of longstanding diabetes. This tends to be associated with diabetic retinopathy. Management is focused on good BP and glycaemic control to prevent progressive decline in eGFR.
Urinary protein measurements will primarily be measured using Albumin Creatinine Ratio (ACR) with Protein Creatinine Ratio (PCR) only checked if urine albumin is > 850mg/mmol.
Microalbuminuria (MA)
Defined as ACR > 3mg/mmol in males and females
Confirmed on at least 2 of 3 ideally early morning samples
Proteinuria
Defined as ACR > 30mg/mmol in males and females
Who can refer:
Primary and Secondary care clinicians
Who to refer:
Consider referral to one of the Joint Renal Diabetes Clinics (at RIE, WGH or SJH) if intensive multi-factorial intervention may help to prevent progression to stage 4 CKD.
We have no set referral criteria but if there is progressive worsening of CKD with rising proteinuria in a patient with modifiable risk factors, we would be happy to consider review.
Who not to refer:
Any patients already under Renal clinic follow up.
Any patients who are frail and wouldn’t benefit from intensive risk factor management
How to refer:
Via SCI Gateway referral to RIE/WGH/SJH (depending on patient’s location) > Diabetes
Primary care management of MA/proteinuria and Diabetes
- Start ACE inhibitor or ARB regardless of BP and titrate to maximum tolerated dose in Type 1 and Type 2 Diabetes
- Add SGLT2 inhibitor if persistent MA/proteinuria in Type 2 Diabetes only:
- Dapagliflozin 10mg once daily (eGFR > 15)
- If frail or elderly, consider whether ACE/ARB/SGLT2 appropriate given known side effects
- Target BP should be individualised based on other co-morbidities
- Most adults with CKD and MA/proteinuria should aim for < 130/80mmHg
- If frail or age > 80, aim < 150/80mmHg or as tolerated
- Optimise HbA1c
- Individualised target but < 58 mmol/mol in most adults
- Start statin if not already taking
ABCD Guidelines for managing hyperglycaemia in patients with diabetes and CKD:
Management of hyperglycaemia in adults with DKD_final (abcd.care)
ABCD and Diabetes UK guidance on use of SGLT2s by non specialists in UK
ABCD guideline on managing hypertension in patients with diabetes and CKD:
Management-of-hypertension-and-RAAS-blockade-in-adults-with-DKD.pdf (abcd.care)
