Investigation of CKD in People with Diabetes - Flow Chart

 

Management of Diabetic Renal Disease

  1. Improve glycaemic control (Target HbA1c <  53 mmol/mol or 7.0%)
  2. Encourage smoking cessation
  3. Apply aggressive targets for control of hypertension
    • Type 1 diabetes <120/70mmHg
    • Type 2 diabetes <130/80 mmHg
  4. Consider introduction of an ACE Inhibitor in Type 1 patients with microalbuminuria or overt proteinuria, even if blood pressure is within target.
    • Remember the possibility of teratogenesis in females of child-bearing age.
  5. Consider introduction of an ACE Inhibitor or ARB, as 1st-line therapy, in Type 2 patients with microalbuminuria or proteinuria, when hypertension is present. Remember the possibility of co-existing renovascular disease. See Handbook section on Screening and Management of Cardiovascular Risk.
  6. In all patients, co-existing cardiovascular risk factors should be managed aggressively.
    • Consider starting Simvastatin 40mg daily and Aspirin 75mg daily

Guidance on use of Metformin in Diabetic Patients with CKD

Metformin therapy may be associated with lactic acidosis and this is more likely to occur in patients with renal impairment. However metformin per se is not nephrotoxic.

Estimated Glomerular Filtration Rate (eGFR) is now routinely calculated and reported by NHS Tayside Biochemical Medicine Labs to aid in the quantification of renal function. In the light of this we have developed the following strategy with colleagues in nephrology:

Action should be taken as outlined below if the eGFR is abnormal on 2 consecutive results at least 6 weeks apart

  • eGFR > 50 no need to alter Metformin.
  • eGFR 30-50 reduce Metformin dose to 500mg BD
  • eGFR <30 stop Metformin

It is worth remembering the following:

  • This is a guideline and as such needs to be interpreted in the light of an individual patient's other co morbidities e.g. heart failure, significant COPD etc, which if present might preclude ongoing therapy at higher eGFR values
  • If Metformin is to be reduced or discontinued then it will be necessary to review the need for additional hypoglycaemic therapy at an early stage
  • In patients who have had a lower extremity amputation, the eGFR may not be truly representative of the renal status and other methods of determining this should be used e.g. measurement of glomerular filtration rate.

 

Back to the topBack to the top of this page

Guidelines for the Combined Diabetes Renal Clinic at Ninewells Hospital and Perth Royal Infirmary

Aims of the clinic

  • To identify, investigate and manage renal disease in patients with diabetes at an early stage, in order to slow the progression to renal failure.
  • To institute aggressive management of glycaemic control and co-existing cardiovascular risk factors where feasible.
  • To screen for metabolic bone disease and renal anaemia and initiate treatment as necessary.
  • To refer onwards to the Low Renal Clearance Clinic in the pre-dialysis phase.

Referral criteria to clinic

  • Estimated GFR <60ml/min in Type 1 diabetes
  • Estimated GFR <40ml/min in Type 2 diabetes
  • Significant Proteinuria (ACR > 70 or PCR > 100) regardless of diabetes type, in the absence of infection.
  • ACR > 35 or PCR > 50 in spite of ACE inhibitor or ARB therapy.
  • Significant deterioration in creatinine following use of ACE inhibitor (increase of 20% above baseline value)
  • Suspicion of non-diabetic renal disease (especially if haematuria present) (i.e. ACR 30 - 69)
  • Patients with persistent proteinuria that is less then the above should be referred to the routine hospital Diabetes Clinic. If in doubt, please discuss with the diabetes team.

Investigations prior to referral

It is helpful to have requested some of the following, where relevant, when patients are referred to this clinic. However, the results of investigations do not need to be available when the referral is made. If in doubt, please discuss with Dr Brennan/Dr Severn (Ninewells) or Dr Pearson/Dr Severn (PRI).

  • Full U&E’s (if only Reflotron creatinine has been checked)
  • Recent dipstick urinalysis
  • Renal ultrasound
  • Immunology screening (ANA, Immunoglobulins, ANCA, CRP) especially if haematuria present
  • Myeloma screening (plasma protein electrophoresis/urine for Bence Jones protein) in patients aged over 50.

Investigation of isolated microscopic haematuria

  • In patients aged <50, this is likely to be due to intrinsic renal disease. Please refer to the Nephrology team.
  • In older patients i.e. aged 50 and over, this is more likely to represent disease of the lower urinary tracts. These patients should have a renal USS and if this is negative, refer to the Urology team. 

 

 Discharge to Low Renal Clearance Clinic (Pre-dialysis patients)

Patients with estimated GFR < 25ml/min (approx.) will be referred to the low GFR clinic for management of anaemia and for counselling regarding possible dialysis. Patients usually attend this clinic every 6-8 weeks. In view of this, they are usually discharged from the Combined Diabetic Renal Clinic and referred back to attend a routine hospital diabetes clinic.

Management of Anaemia in Chronic Kidney Disease

 

See Renal Dialysis Unit Guidelines

 

Back to the topBack to the top of this page