Diabetes CKD

Borders Ref Help Toolkit
NHS Borders

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)

Diabetics- Male ACR >2.5, Female ACR > 3.5

Confirmed on at least 2 of 3 ideally early morning samples

Proteinuria

Defined as ACR > 30mg/mmol in males and females

In the process of diagnosing microalbuminuria or proteinuria please exclude haematuria by doing a urine dip. Haematuria, especially when significant, can artificially increase urinary protein and albumin measurements due to the presence of plasma proteins from red blood cells, leading to inaccurate assessment of albuminuria. Therefore, presence of haematuria is a recognised confounder and should prompt repeat testing after resolution, or further evaluation to determine the underlying cause before confirming a diagnosis of microalbuminuria.

Who to refer, who not to refer, how to refer

Who can refer:

Primary and Secondary care clinicians

Who to refer:

  1. Consider refer to diabetes clinic if heavy proteinuria is confirmed with ACR 70-300 mg/mmol (and help with glycaemic control is needed). Consider referral to renal clinic if renal input is the priority in a patient with rapidly deteriorating renal function.

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

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

Resources and links

Microalbuminuria NHS Borders guidance - Microalbumin.pdf

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

Association of British Clinical Diabetologists (ABCD) and Diabetes UK joint position statement and recommendations for non-diabetes specialists on the use of sodium glucose co-transporter 2 inhibitors in people with type 2 diabetes (January 2021) | RCP Journals

ABCD guideline on managing hypertension in patients with diabetes and CKD:

Management-of-hypertension-and-RAAS-blockade-in-adults-with-DKD.pdf (abcd.care)

Local service details

diabetes.endocrinology@borders.scot.nhs.uk

Editorial Information

Last reviewed: 25/10/2025

Next review date: 25/10/2027

Author(s): Bala Muthukrishnan.

Author email(s): Balakumar.muthukrishnan2@nhs.scot.