Diabetic kidney disease
NHS Tayside RefGuide
Definition
Diabetic kidney disease (DKD) is a clinical diagnosis in a patient with long-standing diabetes (>10 years). Presenting with persistent albuminuria and/or reduced estimated glomerular filtration rate (eGFR) in the absence of signs or symptoms of other primary causes of kidney damage.
Primary care investigation
Primary care investigations involve the measurement of urine albumin creatinine ratio (uACR), (not uPCR) and eGFR. Diagnosis is confirmed if the uACR ≥ 3mg/mmol and/or eGFR < 60 mls/min.
Primary care management is with the intention of stabilising and slowing the progression of CKD and includes both pharmaceutical and non-pharmaceutical treatment. Treatment should be comprehensive and should involve simultaneous management of hyperglycaemia, hypertension, dyslipidaemia, and lifestyle measures.
Primary care management
In patients with type 2 diabetes and DKD, special consideration should be given to the use of agents that reduce the risk of both chronic kidney disease (CKD) progression and CV events.
Primary Care Medication:
In those with T2DM and diabetic kidney disease, initiate both:
- RAAS inhibitor (ACE-inhibitors or ARBs) to maximum tolerated dose, and
- SGLT2i should be initiated for its’ cardiovascular protection, even in the absence of proteinuria, and irrespective of HbA1c.
For patients with T2DM and CKD, please ensure they are on a maximum tolerated dose of RAAS inhibition (or intolerant) and started/trialled on a SGLT2i prior to referral.
Secondary Care Medication:
- Finerenone can be added in if there is persistent protienuria despite RAAS and SGLT2i. Finerenone is initiated by secondary care.
If a DKD patient is on maximum tolerated ACEi or ARB and- SGLT1i, and uACR >30 mg/mmol, please consider referral to Diabetes service, for consideration of finerenone (if eGFR is preserved), or referral to Renal services, if eGFR is reduced (<30 mls/min).
Where the HbA1c remains above target and/or the patient is obese:
- GLP-1 RA have evidence of cardiorenal benefit in proteinuria patients, and should also be considered a pillar of treatment for DKD.
NHS Tayside prescribing guidance for finerenone in DKD
SGLT2i in CKD
Treatment of hyperglycaemia
- Treatments for hyperglycaemia include insulin, other injectable agents, and oral hypoglycaemic agents.
- Patient preference, comorbidities and prescription of certain glucose-lowering medications may be limited by eGFR.
- NHS Tayside’s Diabetes Managed Clinical Network (MCN)
- Intensive lowering of blood glucose with the goal of achieving near-normoglycaemia has been shown to delay the onset and progression of albuminuria and slow eGFR decline in people with type 1 and type 2 diabetes.
- However, glycaemic targets should be individualised to take into consideration key patient characteristics (such as age, disease progression, and macrovascular risk, as well as the patient's lifestyle and disease management capabilities) that may modify risks and benefits of intensive glycaemic control.
Other cardiovascular risk reduction measures for patients with DKD include:
Non pharmacological intervention:
- smoking cessation
- weight loss
- regular aerobic exercise
Control of hypertension:
- To a maximum of 140/90 or 130/80 according to absence/presence of proteinuria (see When to Refer to the Renal Service: According to Proteinuria)
Lipid lowering therapies:
- This should be considered in all patients with CKD, irrespective of serum lipid levels, for primary prevention of CV disease.
- 1st line treatment is atorvastatin 20mg. Increase the dose, if there is not a 40% reduction in non-HDL cholesterol, if eGFR is greater than 30 mls/min.
Primary care monitoring
Monitoring for diabetic kidney disease should be performed as for monitoring of CKD.
Recommended annual number of monitoring checks for people with CKD
Who to refer
Please note that there is not a specific DKD clinic and referral is either to the Diabetes clinic or Renal clinic as outlined below.
Referral to the Diabetes Service should be considered where:
- two consecutive UACR ≥ 70mg/mmol or
- two consecutive UPCR ≥ 100mg/mmol or
- if age<70 and eGFR<45.
Referral to the Renal Services should be considered if a patient with diabetes:
- When there is advanced kidney disease (eGFR <30 mL/minute) requiring discussion of kidney replacement therapy for end-stage kidney disease.
- There is a continuously rising urinary ACR levels and/or continuously declining eGFR, as per guidance on referral criteria on main CKD page: (Sustained decrease in eGFR ≥ 25% AND a change in eGFR category within 12 months OR Sustained decrease in eGFR of ≥ 15 mls/min or 20% rise in serum creatinine within 12 months)
- If there is uncertainty about the aetiology of kidney disease.
- For difficult management issues (anaemia, secondary hyperparathyroidism, significant increases in albuminuria in spite of good BP management, metabolic bone disease, resistant hypertension, or electrolyte disturbances)
How to refer
Routine, urgent and advice referral via SCI-Gateway.
There is 24 hour renal on-call service via the Ninewells Switchboard. (In hours, Monday to Friday, 9 am to 16.30 pm, page #4740. Renal SpR on call until 21.00 pm, Consultant on call overnight, both available via the hospital switchboard.