Diabetic nephropathy screening -
These renal-protective effects also appear to be present in proteinuric individuals with diabetes and normal or near-normal BP. ACE inhibitors have been shown to reduce progression of diabetic kidney disease in albuminuric normotensive individuals with both type 1 81—84 and type 2 diabetes 85, In CKD from causes other than diabetic kidney disease, ACE inhibition has been shown to reduce albuminuria, slow progression of renal disease, and delay the need for dialysis 87, The effectiveness of ACE inhibitors and ARB on loss of renal function appear to be similar in non-diabetic CKD 89, A variety of strategies to more aggressively block the RAAS have been studied in kidney disease, including combining RAAS blockers or using very high doses of a single RAAS blocker.
These strategies reduce albuminuria, but have not been proven to improve patient outcomes in diabetic nephropathy 91—96 , and come at a risk of increased acute renal failure, typically when a patient develops intravascular volume contraction 97,98 and hyperkalemia.
The lack of meaningful impact on loss of renal function through dual RAAS blockade was demonstrated in three randomized controlled trials, including the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial ONTARGET which examined a low renal risk population 97 ; and the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints ALTITUDE study 98 and Veterans Affairs Nephropathy in Diabetes VA NEPHRON-D study 99 which examined people with CKD in diabetes and high renal risk.
As a result of these studies, combination of agents that block the RAAS ACE inhibitor, ARB, direct renin inhibitor [DRI] should not be used in the management of diabetes and CKD.
The impact of adding a mineralocorticoid receptor antagonist to background standard of care including an ACE inhibitor or ARB is being evaluated in the Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease FIDELIO-DKD ClinicalTrials.
gov Identifier NCT and Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease FIGARO-DKD ClinicalTrials. gov Identifier NCT trials and with further evaluate the role of dual RAAS inhibition.
All people with CKD are at risk for CV events, and should be treated to reduce these risks — see Cardiovascular Protection in People with Diabetes chapter, p.
The degree of risk of CV events or progression to ESRD increases as albuminuria levels rise, and as eGFR falls, with the combination of albuminuria and low eGFR predicting a very high level of risk , Three recent CV trials of antihyperglycemic agents in participants with type 2 diabetes with high CV risk have shown renal benefits.
placebo The Canagliflozin Cardiovascular Assessment Study CANVAS Program trial examined an SGLT2 inhibitor in high CV risk type 2 diabetes.
The average eGFR was placebo, but this result was explained by reduction in the new onset of persistent macroalbuminuria rather than effect on doubling of the serum creatinine level, ESRD incidence, or death due to renal disease , In contrast to the GLP-1 receptor agonist trial in which hard renal outcomes were not improved, results from the two independent SGLT2 inhibitor trials showed significant hard renal outcome benefit.
Of note, the presence of CKD stage 3 or lower should not preclude the use of either of these beneficial therapies, although the glucose-lowering efficacy of SGLT2 inhibitors is attenuated as the A1C reduction is proportional to the level of GFR.
Several classes of medications used commonly in people with diabetes can reduce kidney function during periods of intercurrent illness, and should be discontinued when a person is unwell, in particular, when they develop significant intravascular volume contraction due to reduced oral intake or excessive losses due to vomiting or diarrhea.
Diuretics can exacerbate intravascular volume contraction during periods of intercurrent illness. Blockers of the RAAS interfere with the kidney's response to intravascular volume contraction, namely the ability of angiotensin II to contract the efferent arteriole to support glomerular filtration during these periods.
Non-steroidal anti-inflammatories NSAIDs cause constriction of the afferent arterioles, which can further reduce blood flow into the glomerulus, especially in people who are volume contracted. For these reasons, all of these drugs can reduce kidney function during times of intercurrent illness.
A number of additional medications need to be dose-adjusted in people with renal dysfunction, and their usage and dosage should be re-evaluated during periods where kidney function changes see Appendix 8. Sick-Day Medication List. Although these drugs can be used safely in people with ischemic nephropathy, these people may have an even larger rise in serum creatinine when these drugs are used — In the case of severe renal artery stenosis that is bilateral or unilateral in a person with a single functioning kidney , RAAS blockade can precipitate renal failure.
In addition, RAAS blockade can lead to hyperkalemia. People with diabetes and CKD are at a particularly high risk for this complication , This risk is highest with aldosterone antagonists AAs , and the use of AAs without careful monitoring of potassium has been associated with an increase in hospitalization and death associated with hyperkalemia For these reasons, the serum creatinine and potassium should be checked between one and two weeks after initiation or titration of a RAAS blocker Mild to moderate hyperkalemia can be managed through dietary counseling.
Diuretics, in particular furosemide, can increase urinary potassium excretion. If hyperkalemia is severe, RAAS blockade would need to be held or discontinued and advice should be sought from a renal specialist.
As the use during pregnancy of RAAS blockers has been associated with congenital malformations , women with diabetes of childbearing age should avoid pregnancy if drugs from these classes are required.
If a woman with diabetes receiving such medications wishes to become pregnant, then these medications should be discontinued prior to conception see Diabetes and Pregnancy chapter, p. Many antihyperglycemic medications need to have their dose adjusted in the presence of low renal function, and some are contraindicated in people with significant disease.
See Figure 1 in Pharmacologic Glycemic Management of Type 2 Diabetes in Adults chapter, p. S88 and Appendix 7. Therapeutic Considerations for Renal Impairment. Most people with CKD and diabetes will not require referral to a specialist in renal disease and can be managed in primary care.
However, specialist care may be necessary when renal dysfunction is severe, when there are difficulties implementing renal-protective strategies or when there are problems managing the sequelae of renal disease see Recommendation 8 for more details.
A1C, glycated hemoglobin ; ACE, angiotensin converting enzyme ; AA; aldosterone antagonists ; ARB, angiotensinogen receptor blocker; ACR, albumin creatinine ratio ; BP, blood pressure ; CV, cardiovascular ; CVD, cardiovascular disease ; DRI; direct renin inhibitor ; eGFR, estimated glomerular filtration rate ; ESRD, end stage renal disease; GFR; glomerular filtration rate ; NSAIDs; n on-steroidal anti-inflammatories ; RAAS; renin angiotensin aldosterone system.
Literature Review Flow Diagram for Chapter Chronic Kidney Disease in Diabetes. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group P referred R eporting I tems for S ystematic Reviews and M eta- A nalyses: The PRISMA Statement. PLoS Med 6 6 : e pmed For more information, visit www.
McFarlane reports grants and personal fees from Astra-Zeneca, Bayer, Janssen, Novartis, and Otsuka; personal fees from Baxter, Ilanga, Valeant, Servier, and Merck; and grants from Boehringer Ingelheim, outside the submitted work. Cherney reports grants from Boehringer Ingelheim-Lilly, Merck, Janssen, Sanofi and AstraZeneca; and personal fees from Boehringer Ingelheim-Lilly, Merck, AstraZeneca, Sanofi, Mitsubishi-Tanabe, AbbVie and Janssen, outside the submitted work.
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Senior reports personal fees from Abbott, Boehringer Ingelheim, Eli Lilly, Janssen, Merck, mdBriefCase, and Master Clinician Alliance; grants and personal fees from Novo Nordisk, Sanofi, and AstraZeneca; grants from Prometic and Viacyte, outside the submitted work; and is the Medical Director of the Clinical Islet Transplant Program at University of Alberta Hospital, Edmonton, AB.
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Chapter Headings Introduction Diabetic Nephropathy Other Kidney Diseases in People with Diabetes Screening for Kidney Disease in People with Diabetes Screening for Albuminuria Estimation of Glomerular Filtration Rate Other Clinical Features and Urinary Abnormalities—When to Consider Additional Testing or Referral Screening for CKD Prevention, Treatment and Follow Up Treating Kidney Disease Safely Antihyperglycemic Medication Selection and Dosing in CKD Referral to a Specialized Renal Clinic Other Relevant Guidelines Relevant Appendices Related Websites Author Disclosures.
Key Messages Identification of chronic kidney disease in people with diabetes requires screening for proteinuria, as well as an assessment of serum creatinine converted into an estimated glomerular function rate eGFR.
All individuals with chronic kidney disease should be considered at high risk for cardiovascular events and should be treated to reduce these risks.
The development and progression of renal damage in diabetes can be reduced and slowed through intensive glycemic control and optimization of blood pressure. Progression of chronic kidney disease in diabetes can also be slowed through the use of medications that disrupt the renin angiotensin aldosterone system.
Key Messages for People with Diabetes The earlier that the signs and symptoms of chronic kidney disease in diabetes are detected, the better, as it will reduce the chance of progression to advanced kidney disease and the need for dialysis or transplant.
You should have your blood and urine tested annually for early signs of chronic kidney disease in diabetes.
If you are found to have signs of chronic kidney disease, your health-care provider may recommend lifestyle or medication changes to help delay more damage to your kidneys.
Practical Tips Management of Potassium and Creatinine During the Use of Angiotensin Converting Enzyme ACE inhibitor or Angiotensin II Receptor Blocker ARB or Direct Renin Inhibitor DRI Therapy Check serum potassium and creatinine at baseline and within 1 to 2 weeks of initiation or titration of therapy AND during times of acute illness.
Mild-to-moderate stable hyperkalemia: Counsel on a low-potassium diet. Consider temporarily reducing or holding RAAS blockade i. ACE inhibitor, ARB or DRI.
Severe hyperkalemia: In addition to emergency management strategies, RAAS blockade should be held or discontinued. Introduction Diseases of the kidney are a common finding in people with diabetes, with up to one-half demonstrating signs of renal damage in their lifetime 1—3.
Figure 1 Causes of CKD in people with and without diabetes. CKD, chronic kidney disease. Other Kidney Diseases in People with Diabetes Diabetic nephropathy is a major cause of CKD in diabetes; however, people with diabetes can also get CKD from other causes, including hypertensive nephrosclerosis or ischemic nephropathy from atherosclerotic changes to small or large renal arteries.
Screening for Chronic Kidney Disease in People with Diabetes Screening for CKD in people with diabetes involves an assessment of urinary albumin excretion and a measurement of the overall level of kidney function through an eGFR.
Table 1 Stages of diabetic nephropathy by level of urinary albumin level ACR, albumin to creatinine ratio; CKD, chronic kidney disease. Table 2 Clinical and laboratory factors favouring the diagnosis of classical diabetic kidney disease or an alternative renal diagnosis eGFR, estimated glomerular filtration rate.
Screening for Albuminuria When screening for albuminuria, the test of choice is the random urine albumin to creatinine ratio urine ACR. Figure 3 A flowchart for screening for CKD in people with diabetes.
Estimation of Glomerular Filtration Rate The serum creatinine is the most common measurement of kidney function, however, it can inaccurately reflect renal function in many scenarios, particularly in extremes of patient age or size 38, Table 4 Stages of CKD of all types.
Other Clinical Features and Urinary Abnormalities—When to Consider Additional Testing or Referral Urinalysis findings of red or white blood cell casts or heme granular casts suggest a renal diagnosis other than diabetic kidney disease. Screening for CKD People with diabetes should undergo annual screening for the presence of diabetes-related kidney disease when they are clinically stable and not suspected to have non-diabetic kidney disease or an AKI.
Prevention, Treatment and Follow Up Glycemic control Optimal glycemic control established as soon after diagnosis as possible will reduce the risk of development of diabetic kidney disease 44— Blood pressure control Optimal BP control also appears to be important in the prevention and progression of CKD in diabetes, although the results have been less consistent 47,51,61— Blockade of the renin angiotensin aldosterone system Blockade of the renin angiotensin aldosterone system RAAS with either an angiotensin converting enzyme ACE inhibitor or an angiotensin receptor blocker ARB can reduce the risk of developing CKD in diabetes independent of their effect on BP.
Other interventions All people with CKD are at risk for CV events, and should be treated to reduce these risks — see Cardiovascular Protection in People with Diabetes chapter, p.
Antihyperglycemic Medication Selection and Dosing in CKD Many antihyperglycemic medications need to have their dose adjusted in the presence of low renal function, and some are contraindicated in people with significant disease.
Referral to a Specialized Renal Clinic Most people with CKD and diabetes will not require referral to a specialist in renal disease and can be managed in primary care. Recommendations To prevent the onset and delay the progression of CKD, people with diabetes should be treated to achieve optimal control of BG [Grade A, Level 1A 45,46 see Recommendations 2 and 3, Targets for Glycemic Control chapter, p.
S42 and BP [Grade A, Level 1A 61,65,96 ]. In adults with diabetes, screening for CKD should be conducted using a random urine ACR and a serum creatinine converted into an eGFR [Grade D, Consensus].
Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and 5 years after diagnosis in adults with type 1 diabetes and repeated yearly thereafter [Grade D, Consensus]. All people with diabetes and CKD should receive a comprehensive, multifaceted approach to reduce CV risk [Grade A, Level 1A , ] see Cardiovascular Protection in People with Diabetes chapter, p.
Adults with diabetes and CKD with either hypertension or albuminuria should receive an ACE inhibitor or an ARB to delay progression of CKD [Grade A, Level 1A for ACE inhibitor use in type 1 and type 2 diabetes, and for ARB use in type 2 diabetes 69,75,77—81,84—86 ; Grade D, Consensus for ARB use in type 1 diabetes].
People with diabetes on an ACE inhibitor or an ARB should have their serum creatinine and potassium levels checked at baseline and within 1 to 2 weeks of initiation or titration of therapy and during times of acute illness [Grade D, Consensus].
Sick-Day Medication List [Grade D, Consensus]. Combinations of ACE inhibitor, ARB or DRI should not be used in the management of diabetes and CKD [Grade A, Level 1 95,98 ]. Abbreviations: A1C, glycated hemoglobin ; ACE, angiotensin converting enzyme ; AA; aldosterone antagonists ; ARB, angiotensinogen receptor blocker; ACR, albumin creatinine ratio ; BP, blood pressure ; CV, cardiovascular ; CVD, cardiovascular disease ; DRI; direct renin inhibitor ; eGFR, estimated glomerular filtration rate ; ESRD, end stage renal disease; GFR; glomerular filtration rate ; NSAIDs; n on-steroidal anti-inflammatories ; RAAS; renin angiotensin aldosterone system.
Other Relevant Guidelines Targets for Glycemic Control, p. S42 Monitoring Glycemic Control, p. S47 Pharmacologic Glycemic Management of Type 2 Diabetes in Adults, p. S88 Treatment of Hypertension, p. S Diabetes and Pregnancy, p.
Relevant Appendices Appendix 7. Therapeutic Considerations for Renal Impairment Appendix 8. Author Disclosures Dr. References Warram JH, Gearin G, Laffel L, et al. J Am Soc Nephrol ;—7.
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Imaging tests are noninvasive tests that create an image of the organs, bones, or tissues inside the body. There are three common types of imaging tests used to screen for diabetes nephropathy:. Also called a renal ultrasound , it uses sound waves to produce a real-time video image of the inside of the body.
A CT scan uses X-rays to create a 3D cross-section image of the inside of the body. Some CT scans require a contrast agent, also referred to as a dye, to be introduced to the body, either by injection or ingestion, to improve the image quality.
Also referred to as a renal biopsy , this test removes a small piece of the kidneys for examination. The biopsy is done using a needle or with minor surgery. A biopsy can uncover scarring, inflammation, or protein deposits that cannot be uncovered using other tests.
You can lower your risk of diabetes-related kidney disease by regularly monitoring and managing your glucose levels and kidney health, along with getting annual health screens. The general guideline for people with diabetes is to get their kidney function screened every year.
For people with type 2 diabetes , screenings begin at diagnosis. For people with type 1 diabetes , screenings can begin 5 years after diagnosis. Kidney disease symptoms are often subtle and easily missed. Because of this, certain risk factors can point to the need to be more diligent about screening.
According to the National Kidney Foundation , these risk factors include:. EGFR results are more precise and used to identify specific stages of kidney disease. Generally, an eGFR above 90 is considered healthy. Below that, the results are divided into stage 1 mild kidney damage through stage 5 kidney failure.
Diabetic nephropathy is a common diabetes complication. According to the National Institute of Diabetes and Digestive and Kidney Diseases NIDDK , 1 in 3 people with diabetes have kidney disease in the United States.
Over time, the kidneys lose their ability to filter waste from the blood and eventually fail completely. When the kidneys no longer work, dialysis or an organ transplant is needed to stay alive. Diabetes nephropathy is also difficult to detect. Common symptoms, such as nausea, changes in urination, swelling limbs, or muscle aches, may be easily dismissed or confused with other conditions.
Regular screenings are the most effective way to monitor changes in kidney health. They can make early detection possible so treatment and lifestyle changes can slow or stop the progression of diabetic nephropathy. Regularly screening your kidney health is a part of actively managing diabetes.
Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. People with kidney disease and diabetes should monitor their intake of certain nutrients. Here are 5 foods to avoid with kidney disease and diabetes.
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One of the most common electrolyte imbalances experienced by people with kidney disease, which can lead to muscle weakness, pain, or even paralysis…. A low GFR may be an indicator of kidney…. High protein levels in the urine are known as proteinuria. Discover 11…. A urine protein test measures the amount of protein in urine.
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Diabetic nephropathy Diabetic nephropathy screening called diabetic kidney disease is the leading cause Diabetic nephropathy screening kidney failure in the Diabstic States. According to the Scrwening for Disease Nephropaghy and Diabetic nephropathy screening, inapproximately 44 percent nephopathy all new nephroparhy of kidney failure were caused by diabetes mellitus; 48, persons with diabetes began treatment for end-stage renal disease ESRD ; andpersons with ESRD caused by diabetes were on long-term dialysis or had a renal transplant. Renal Data System report, Risk factors associated with development of microalbuminuria include higher blood pressure, higher blood glucose level, dyslipidemia, and smoking. Several studies have analyzed the effectiveness and cost-effectiveness of diabetic nephropathy screening. Diabetes-related nephropathy scdeening, also referred Diabetic nephropathy screening as diabetic nephropathy or diabetic kidney disease Bone health supplementsDiabetic nephropathy screening a potentially fatal diabetes complication. Chronically high blood glucose levels damage blood screenng in the kidneys. Diabetic nephropathy screening time, the nephropathj lose their ability to filter waste from the blood and will eventually fail completely. When this happens, dialysis or an organ transplant is needed to stay alive. There is no cure for diabetic nephropathy, but when caught early, its progression can be slowed or stopped. Several types of tests are used to screen for diabetic nephropathy. Screening is an important part of managing kidney health for people with diabetes.
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