Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives
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.
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.
Tools for Clinicians and Educators
Key Tools and Resources
National Kidney Disease Education Program.
IHS Division of Diabetes Treatment and Prevention.
National Collaborating Centre for Chronic Conditions.
National Kidney Disease Education Program.
Patient Education Materials
National Institute of Diabetes and Digestive and Kidney Diseases. Prevent Diabetes Problems: Keep Your Kidneys Healthy. [PDF] NIH Publication No. 10–4281. 2010.
National Kidney Disease Education Program and Indian Health Service Division of Diabetes Treatment and Prevention.
National Kidney Disease Education Program
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. 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. [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. [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. [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. 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. [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. [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. London: Royal College of Physicians; 2008 Sep. 204 p.
Narva, AS. Reducing the burden of chronic kidney disease among American Indians. Adv Chronic Kidney Dis. 2008;15:168-73.
Nelson RG, Pavkov ME, Hanson RL, Knowler WC. Changing course of diabetic nephropathy in the Pima Indians. Diabetes Res Clin Pract. 2008;82 Suppl 1: S10-4.
Pavkov ME, Knowler WC, Hanson RL, Bennett PH, Nelson RG. Predictive power of sequential measures of albuminuria for progression to ESRD or death in Pima Indians with type 2 diabetes. Am J Kidney Dis. 2008;51(5):759-66.
Pavkov ME, Knowler WC, Hanson RL, Nelson RG. Diabetic nephropathy in American Indians, with a special emphasis on the Pima Indians. Curr Diab Rep. 2008;8:486-93.
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. [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. [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. [PDF] J Am Soc Nephrol. 2009;20(3):629-37.
Schwartz GJ, Work DF. Measurement and estimation of GFR in children and adolescents. [PDF] Clin J Am Soc Nephrol. 2009 Nov;4(11):1832-43.
Van Wyck DB, Eckardt K, Adamson JW, Bailie GR, Berns JS, Fishbane S, et al.; Anemia in Chronic Kidney Disease Work Group. National Kidney Foundation (NKF)-Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease. New York: National Kidney Foundation; 2006.
Vassalotti JA, Stevens LA, Levey AS. Testing for chronic kidney disease: a position statement from the National Kidney Foundation. Am J Kidney Dis. 2007;50(2):169-80.
Zelmanovitz T, Gerchman F, Balthazar APS, Thomazelli FCS, Matos JD, Canani LH. Diabetic nephropathy: review. Diabetol Metab Syndr [Internet]. 2009 Sep;doi:10.1186./1758-5996-1-10.