U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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Monday, November 24, 2014

Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives


Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes

Last updated: July 2012

Kidney Care

Diabetes significantly increases the risk of developing chronic kidney disease. The AI/AN population used to have the highest incidence rate of end-stage renal disease (ESRD) among patients with diabetes. While still higher than for several other groups, the rate has decreased significantly in recent years, due at least in part to good clinical care of patients with diabetes. To continue this trend toward lower rates of ESRD, emphasis on improving CKD prevention, screening, monitoring, and treatment is as important as ever in AI/AN people with diabetes.

Clinical Practice Recommendations

Kidney Care

recommendations icon Recommendations for Kidney Disease

  • Order serum creatinine/estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) at diabetes diagnosis and then at least annually thereafter.
  • Consider nephrology consultation if the etiology of the chronic kidney disease (CKD) is unclear, if CKD is progressing rapidly, if there is any difficulty managing CKD complications, and if eGFR is < 30 mL/min/1.73 m2.
  • Set and achieve individualized blood pressure targets (e.g., < 130/80 mmHg, < 140/90 mmHg, etc.) for all patients with diabetes:
    • Prescribe an ACE inhibitor or ARB for all patients with diabetes and hypertension, unless contraindicated.
  • Begin laboratory testing, monitoring, and treatment of CKD complications such as anemia and metabolic bone disease when patients’ eGFR < 60 mL/min/1.73 m2.

Screening and Monitoring to Assess Kidney Status: eGFR and UACR

Screening includes an assessment of eGFR and a measurement of urinary protein excretion – the spot UACR. These tests should be done at diabetes diagnosis and repeated at least annually – more often, if results are changing rapidly or to assess the effectiveness of interventions.

Use the eGFR and UACR to screen for, diagnose, and monitor the progression of CKD, and to assess the effectiveness of interventions. These tests are continued for the life of the patient, regardless of the stage of kidney disease or types of treatment provided. However, once a patient is on dialysis, these tests no longer are indicated.

Estimated Glomerular Filtration Rate (eGFR)

The eGFR is an estimation of the kidneys’ ability to filter blood and is based on a calculation that includes serum creatinine, body weight, and age. Equations used to calculate eGFR include the Modification of Diet in Renal Disease Study Group (MDRD) Exit Disclaimer: You Are Leaving www.ihs.gov and Cockcroft-Gault equations. While the Cockcroft-Gault equation may still be used for medication dosing, the MDRD is the preferred equation for CKD assessment for adults with diabetes. For youth < 18 years of age, a different equation, the Bedside Schwartz equation Exit Disclaimer: You Are Leaving www.ihs.gov should be used.

The Resource and Patient Management System (RPMS) calculates the eGFR automatically using the MDRD equation when a serum creatinine test is ordered. Because the MDRD equation estimates do not produce reliable results when > 60 mL/min/1.73m2, these results are reported simply as “above 60.” Thus, it is not possible to distinguish clinically between Stages 1 and 2 of CKD.

Urine Albumin-to-Creatinine Ratio (UACR)

The UACR is the test recommended to assess urine albumin excretion and is reported as the ratio of milligrams of albumin to grams of creatinine (mg/g). The UACR is a quantitative test, performed using a single spot urine specimen. Twenty-four hour urine collections are no longer needed nor recommended for routine diabetes nephropathy screening. Also, semi-quantitative “test strips” for urine protein are not sufficiently accurate for CKD diagnosis and monitoring.

The definitions of normal and abnormal albumin excretion on a UACR test are:

  • Normoalbuminuria < 30 mg/g
  • Albuminuria ≥ 30 mg/g:
    • Microalbuminuria 30-300 mg/g
    • Macroalbuminuria > 300 mg/g.

Because of variability in urinary albumin excretion, at least 2 specimens (preferably first morning void) collected within a 3- to 6-month period should be abnormal before considering a patient to have crossed one of these diagnostic thresholds. Factors that may elevate urinary albumin over baseline values include exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, pregnancy, marked hypertension, urinary tract infection, and hematuria.

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Diagnosis of Chronic Kidney Disease

Chronic kidney disease (CKD) is defined as ≥ 3 months duration of either:

  • Decreased kidney function: eGFR < 60 mL/min/1.73 m2, or
  • Evidence of kidney damage: albuminuria (e.g., UACR ≥ 30 mg/g) or abnormalities on kidney blood tests, imaging, or biopsy.

Stages of Chronic Kidney Disease (CKD)

Stages of CKD 1* 2* 3 4 5

* Distinguishing Stage 1 from Stage 2 CKD is not possible in clinical settings.

eGFR, mL/min > 60 > 60 30-59 15-29 < 15

In adults with diabetes, the most likely cause of CKD is the diabetes itself. However, not all CKD in patients with diabetes is due to diabetic nephropathy and it is important to look out for patients whose CKD pattern (e.g., significant albuminuria early in the course of diabetes, a rapid rise in urine albumin excretion) suggests another etiology. These patients should be referred to a nephrologist for further testing (e.g., kidney biopsy) for a definitive diagnosis and treatment plan.

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Monitoring and Treatment of Chronic Kidney Disease

Once CKD and its cause(s) are established, there are effective treatments that can delay progression to ESRD and improve quality of life. CKD further increases CVD risk in patients with diabetes. Therefore, modification of CVD risk factors, including tobacco cessation, lipid control, and blood pressure control, is essential.

Treatment of blood pressure requires diligent efforts to achieve targets. For those patients who can achieve a target of < 130/80 mmHg without adverse symptoms, this target may be selected. For other patients, a target of < 140/90 mmHg (or higher if symptoms and comorbidities dictate) should be selected.

The use of ACE inhibitors or ARBs should be considered for all patients with diabetes and hypertension, and/or albuminuria. In addition to lowering blood pressure, these medications also decrease the rate of urinary albumin excretion. Monitoring patients’ serial UACR results will help assess the effectiveness of interventions, and also is prognostic as to the rate of kidney decline. Laboratory testing, monitoring, and treatment of CKD complications such as anemia and metabolic bone disease become important in patients with eGFR < 60 mL/min/1.73 m2.

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Resources

Tools for Clinicians and Educators

additional resources icon Additional Resources

IHS Division of Diabetes Treatment and Prevention.

National Collaborating Centre for Chronic Conditions.

National Kidney Disease Education Program.

  • Chronic Kidney Disease (CKD) Information. Exit Disclaimer: You Are Leaving www.ihs.gov
    Web-based resources for health professionals include CKD treatment guides, nephrology referral form, patient education materials, and fact sheets.
  • CKD and Nutrition. Exit Disclaimer: You Are Leaving www.ihs.gov 2011.
    Website designed for general practice registered dietitians (RDs) to provide effective medical nutrition therapy to CKD patients who are not yet on dialysis, includes an overview guide for RDs, tools for assessment and education of test results with patients, and nutrition handouts for people with CKD.
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Patient Education Materials

National Institute of Diabetes and Digestive and Kidney Diseases. Prevent Diabetes Problems: Keep Your Kidneys Healthy. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 10–4281. 2010.

  • Easy-to-read illustrated booklet describing diabetes self-care to reduce risk for chronic kidney disease (available in large or standard format).

National Kidney Disease Education Program and Indian Health Service Division of Diabetes Treatment and Prevention.

National Kidney Disease Education Program

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Bibliography

Chronic Kidney Disease Prognosis Consortium. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Exit Disclaimer: You Are Leaving www.ihs.gov Lancet. 2010 Jun 12;375(9731):2073-81.

Di Angelantonio E, Chowdhury R, Sarwar N, Aspelund T, Danesh J, Gudnason V. Chronic kidney disease and risk of major cardiovascular disease and non-vascular mortality: prospective population based cohort study. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  BMJ. 2010;341:c4986.

Holman RR, Paul SK, Bethel MA, Neil AW, Matthews DR. Long-term follow-up after tight control of blood pressure in type 2 diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  N Eng J Med. 2008;359(15):1565-76.

Kim NH, Pavkov ME, Knowler WC, Hanson RL, Weil EJ, Curtis JM, et al. Predictive value of albuminuria in American Indian youth with or without type 2 diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Pediatrics. 2010;125:e844-51.

Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al.; National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Exit Disclaimer: You Are Leaving www.ihs.gov   Ann Intern Med. 2003 Jul 15;139(2):137-47. Erratum in: Ann of Intern Med. 2003 Oct 7;139(7):605.

McFarlane SI, Chen S, Whaley-Connell AT, Sowers JR, Vassalotti JA, Salifu MO, et al. Prevalence and associations of anemia of CKD: Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES) 1999-2004. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Am J Kidney Dis. 2008;51 4 Suppl 2:S46-55.

Miller WG. Estimating glomerular filtration rate. Clin Chem Lab Med. 2009;47:1017-9.

National Kidney Disease Education Program (US). Urine albumin-to-creatinine ratio (UACR) in evaluating patients with diabetes for kidney disease. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Bethesda (MD): National Institutes of Health; 2010. 2 p. (NIH Publication No. 10-6286).

National Collaborating Centre for Chronic Conditions. Chronic kidney disease: national clinical guideline for early identification and management in adults in primary and secondary care. Exit Disclaimer: You Are Leaving www.ihs.gov London: Royal College of Physicians; 2008 Sep. 204 p.

Narva, AS. Reducing the burden of chronic kidney disease among American Indians. Exit Disclaimer: You Are Leaving www.ihs.gov Adv Chronic Kidney Dis. 2008;15:168-73.

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Pavkov ME, Mason CC, Bennett PH, Curtis JM, Knowler WC, Nelson RG. Change in the distribution of albuminuria according to estimated glomerular filtration rate in Pima Indians with type 2 diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2009;32(10):1845-50.

Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, et al.; American Diabetes Association. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus: a position statement of the American Diabetes Association. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2011 Jun;34(6):1419-23.

Schwartz GJ, Muñoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, et al. New equations to estimate GFR in children with CKD. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  J Am Soc Nephrol. 2009;20(3):629-37.

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Division of Diabetes Treatment and Prevention | Phone: (505) 248-4182 | Fax: (505) 248-4188 | diabetesprogram@ihs.gov