New guidelines developed for the first time by the Kidney Disease Outcomes Quality Initiative provide detailed information on how to improve clinical outcomes in patients who have both diabetes and chronic kidney disease. The guidelines emphasize tight control of glucose, blood pressure, and lipids, along with frequent monitoring of urinary protein. Dr. Nelson of the National Institutes of Health in Phoenix offered a preview of the guidelines, which will be published this fall in the American Journal of Kidney Diseases.
The Kidney Disease Outcomes Quality Initiative guidelines recommend that people with type 1 diabetes undergo screening for diabetic kidney disease 5 years after diagnosis, and then annually. In type 2 diabetics, annual screening should begin at diagnosis.
Screening can consist of obtaining spot urine samples for an albumin/creatinine ratio—at least two samples within 3 months, Dr. Nelson noted.
If the urine albumin/creatinine ratio exceeds 300 mg/g, a number consistent with macroalbuminuria, diabetic kidney disease can be diagnosed without doing a renal biopsy. In addition, patients with microalbuminuria who also have retinopathy are considered to have diabetic kidney disease.
Clues to the diagnosis of nondiabetic kidney disease in diabetic patients include lack of diabetic nephropathy, a rapid decrease in glomerular filtration rate, and sudden onset of nephropathy.
Solid research evidence shows that the cornerstone of managing patients with diabetic kidney disease is maintaining a target hemoglobin A1c of 7% or below, Dr. Nelson said, citing the Diabetes Control and Complications Trial (N. Engl. J. Med. 1993;329:977–86).
Hypertension also must be managed aggressively in patients with diabetic kidney disease. Both ACE inhibitors and angiotensin-receptor blockers (ARBs), often given with a diuretic, can help patients achieve the goal blood pressure of 130/80 mm Hg or lower. “We believe that the efficacy of ACE inhibitors and ARBs are similar,” Dr. Nelson said. Achieving the blood pressure goal is a very important preventive measure, and clinicians can use additional classes of antihypertensive medication as needed to accomplish this goal.
Patients with diabetic kidney disease also are likely to have dyslipidemia. Evidence indicates that treating lipid disorders provides cardiovascular protection in these patients, Dr. Nelson pointed out. Patients with diabetes and stages 1–4 chronic kidney disease should be treated with a statin to achieve an LDL cholesterol level of 100 mg/dL or less.
In addition to tight control of blood glucose levels, hypertension, and dyslipidemia, the final treatment recommendation for diabetic patients with chronic kidney disease is one that is frequently overlooked: a low-protein diet.
Dr. Nelson indicated that patients should eat no more than 0.8 g protein per kilogram of body weight daily. “A lot of people eat a lot more than this.”
“The incidence of diabetes with end-stage renal disease is increasing by leaps and bounds,” noted Dr. Nelson. Within the United States, Hispanics are the ethnic group with the highest proportion of diabetes-related ESRD, with 65% of the ESRD in that group due to diabetes.
Dr. Robert Nelson Presented the new recommendations at a meeting on clinical nephrology sponsored by the National Kidney Foundation. The New guidelines, will be published this fall in the American Journal of Kidney Diseases.
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