Diabetes Standards of Care and Resources for Clinicians and Educators

The estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) are used to screen, diagnose, and monitor chronic kidney disease (CKD). The eGFR provides an estimate of the kidneys’ ability to filter blood, and an abnormal UACR can indicate kidney damage.

Screening

• Measure serum creatinine and calculate eGFR at diabetes diagnosis. Repeat this test at least annually. The eGFR is a measure of kidney function.
  • eGFR is calculated using serum creatinine, body weight, and age. (Estimating equations which also include race as a variable are no longer recommended.)
• Measure urine albumin and creatinine and calculate UACR (mg/g) at diabetes diagnosis. Repeat these tests at least annually.
  • UACR estimates 24 hour urine albumin excretion (mg albumin/g creatinine approximates mg albumin/day).
  • UACR is determined by dividing the urine albumin concentration (mg/dL) by the urine creatinine concentration (g/dL) in a spot urine specimen.

Note: Other factors such as volume status, medications, nutritional status, and infection can affect eGFR and UACR.

Diagnosis

• Diagnose CKD when the following are present for at least 3 months:
  • Decreased kidney function: eGFR <60 mL/min/1.73 m²
    and/or
  • Evidence of kidney damage: UACR ≥30 mg/g (albuminuria) or abnormalities on kidney blood tests, imaging, or biopsy
• Stage CKD
  • Increasing albuminuria and declining eGFR predict worse outcomes. The stage of CKD indicates severity and predicts the risk of progression to end-stage renal disease (ESRD). However, eGFR and UACR are continuous variables so transition from one "stage" to another should not be over-emphasized beyond indicating decreased function and increased complications.

CKD Stage	1 and 2	3	4	5
eGFR (mL/min/1.73m2)	≥60	30-59	15-29	<15
and UACR (mg/g)	≥30	*	*	*
* At CKD stages 3-5 albuminuria may be present at any value

 

• Evaluate for other non-diabetic etiologies of CKD
  • CKD in people with diabetes may be due to other causes, such as chronic infections or autoimmune conditions, as well as diabetic kidney disease.
  • Consider additional evaluation for non-diabetes causes of CKD.
    • CMP, UA, Uric Acid, PO4, ANA, RF, C3, C4, HepBsAg, HepCAb, and HIV
    • If patient is older than 40 years, check serum protein electrophoresis and urine protein electrophoresis for abnormal proteins
    • Retinal examination (Kidney disease and retinopathy often occur together. Absence of retinopathy may indicate another etiology for CKD.)
    • Renal ultrasound

Blood Pressure Management

Blood Pressure control is the most effective CKD intervention for renal protection.

• Aim for a blood pressure <140/90 mmHg for most patients. See Hypertension Therapy in Type 2 Diabetes Algorithm. [PDF – 99 KB]
• Consider a lower blood pressure target for patients with cardiovascular disease, heart failure, or high risk of CKD progression, if treatment is tolerated.
• Prescribe ACE inhibitors or ARBs for patients with both hypertension and albuminuria (>30 mg/g) to prevent or delay progression of CKD, unless contraindicated. ACE inhibitors and ARBs should not be used together.
• Consider ACE inhibitor or ARB treatment for patients who have albuminuria (>300 mg/g) but normal blood pressure if treatment has no burdensome side effects.
• For all patients treated with ACE inhibitors or ARBs:
  • Counsel patients to limit dietary sodium to help control blood pressure and optimize the benefit of these medications; excess sodium negates their therapeutic effects.
  • Monitor blood creatinine and potassium levels within 2-4 weeks of initiating and increasing dose.
  • If hyperkalemia develops, address and treat other causes before discontinuing or reducing dose.
  • Monitor UACR to assess the effectiveness of this therapy.
  • Continue therapy in patients with eGFR <30, if tolerated.

Diabetes Management

Aim for an A1C level <7% for most patients. A1C and blood sugar target ranges should be individualized based on risks and benefits of therapy and patient preferences. See Glucose Management in Type 2 Diabetes Algorithm. [PDF – 203 KB]

• Consider kidney function when prescribing or renewing medications to manage blood glucose.
  • Use metformin for initial hyperglycemia treatment. Consider reducing dose as CKD progresses, discontinue if eGFR is <30.
  • Monitor closely for hypoglycemia with declining renal function, particularly in patients taking insulin and/or sulfonylurea. Stop and/or adjust doses as needed.
  • Note that A1C measurement may be inaccurate in patients with CKD Stage 4 & 5, in patients with hemoglobinopathies, or with increased red cell turnover (e.g., dialysis).
• Consider SGLT-2 inhibitor independent of A1C when eGFR is 30-60 or UACR is ≥30 to reduce risk of CKD progression. Consult renal dosing guidelines if eGFR is <45.
• Consider GLP-1 receptor agonist independent of A1C to reduce the risk of CKD progression.

Cardiovascular Risk Management

People with diabetes and CKD are at high risk for ischemic heart disease, stroke, and/or peripheral vascular disease. Albuminuria is also associated with cardiovascular disease (CVD) risk and mortality.

• Address CVD risk.
  • Prescribe statin therapy in accordance with the 2018 AHA/ACC Guideline on the Management of Blood Cholesterol. Exit Disclaimer: You Are Leaving www.ihs.gov 
  • Consider antiplatelet therapy.
  • Provide tobacco cessation counseling and treatment.
  • Advise patients to avoid and/or limit exposure to secondhand smoke.

Note: See Lipid and Aspirin Therapy in Type 2 Diabetes Algorithm [PDF – 170 KB] for specific guidance.

Medication Safety and Sick Day Management

• Review over-the-counter medications, herbal, and nutritional supplement use.
• Check prescribing guidelines for renal dosing of any medication when eGFR is <30.
• Avoid non-steroidal anti-inflammatory drug (NSAID) use to decrease the risk of kidney damage.
• Recommend more frequent glucose monitoring and counsel patients on diabetes medication adjustments during acute illness.
• Counsel to reduce or hold diuretics, ACE inhibitors, ARBs, and do not use NSAIDs during acute, potentially volume-depleting illnesses (e.g. gastroenteritis, acute viral syndrome) to reduce the risk of acute kidney injury (AKI).
• Advise patients when to restart withheld medications.

Case Management

Case management is an important strategy for providing patient-centered care. In the early stages of CKD, the emphasis is to support patients in the management of CKD and to preserve kidney function. As CKD progresses, case managers play a critical role in the coordination of care and services needed to address CKD complications and to prepare for potential renal replacement therapy.

• Provide education to patients about their condition and self-care behaviors to prevent or delay further decline.
• Coordinate services for early attention to CKD complications that require closer monitoring of clinical interventions.
• Create and manage a registry/list of patients who require more intensive interventions.
• Facilitate opportunities for patients to receive behavioral health support.
• Work with patient, family, and primary care team to ensure that patient’s diabetes care, other health issues, and concerns are addressed.

Renal Nutrition Therapy

• Refer to a registered dietitian for medical nutrition therapy based on CKD progression. To facilitate efficient evaluation consider using the CKD Diet Counseling (Medical Nutrition Therapy) Referral Form. Exit Disclaimer: You Are Leaving www.ihs.gov 
• Assist patients with setting appropriate goals for weight and physical activity.
• Advise patients to limit sodium (<2300 mg/day) to help lower blood pressure and reduce fluid overload.
  • Aim for low sodium (5% or less) per serving on food labels.
  • Avoid salt substitutes.(Note: many salt substitutes and low sodium diets have increased potassium.)
• Assess protein intake and advise to avoid excessive protein intake.
• Monitor labs for potassium and phosphorus levels; advise to limit dietary intake with declining renal function as needed.

Referrals

• Refer patients to nephrologist for diagnostic or therapeutic questions or for preparation for renal replacement therapy. To facilitate efficient evaluation and consultation consider using the Nephrology Referral Form. [PDF – 392 KB]

As renal function declines, the complications of CKD require closer monitoring and clinical interventions. See Manage Patients with Chronic Kidney Disease Exit Disclaimer: You Are Leaving www.ihs.gov  from the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK).

Laboratory Monitoring

• Measure UACR and eGFR at least annually to monitor rate of change and treatment effect.
• Measure electrolytes, hemoglobin, calcium, phosphorus, and albumin annually. More frequent monitoring is required based on CKD stage and rate of CKD progression.

Metabolic Acidosis

Metabolic acidosis (bicarbonate <22 mEq/L) can become more severe with worsening CKD. It can contribute to hyperkalemia.

• Start sodium bicarbonate 325-650 mg BID (or TID) if bicarbonate (CO2) is <22mEq/L.
• Monitor for fluid retention with sodium bicarbonate therapy. Occasionally, starting or increasing diuretic dose is necessary.

Anemia in CKD

Anemia is common as CKD progresses due to decreased red blood cell production.

• Test for other correctable causes of anemia: vitamin B12, folate, iron studies (Fe, percent saturation, TIBC, ferritin, and transferrin saturation), CBC with diff, and stool for occult blood.
• Start ferrous sulfate 325 mg QD to TID if iron studies are low.
• Consider IV iron and/or erythropoiesis stimulating agents for patients with anemia unresponsive to oral iron.

Edema/ Fluid Overload

Fluid retention in CKD is caused by many contributing factors that require close monitoring.

• Advise sodium restriction (<2300 mg/d). Refer to dietitian.
• Use diuretics (thiazide, loop diuretics) for fluid retention. Start with loop diuretics in patients with eGFR <30.
• Monitor diuresis: blood pressure and labs (BUN/Cr) in patients with edema and low serum albumin.

Hyperkalemia

Hyperkalemia is a common but potentially serious complication of progressive CKD which may require active interventions.

• Refer to dietitian for potassium restriction. (Note: many salt substitutes and low sodium diets have increased potassium.)
• Treat acidosis, use loop diuretic, or lower the dose of ACEI/ARB to normalize potassium.

Mineral and Bone Disorders (MBD)

The goals for managing MBD in people with CKD are to decrease serum phosphate and maintain normal calcium levels to mitigate soft tissue calcifications and renal osteodystrophy.

• Refer patients to a dietitian for dietary phosphorus restriction, including processed meats and soft drinks.
• Start phosphate-lowering therapy if the patient’s phosphate level is >4.6 mg/dL. See Chronic Kidney Disease in Type 2 Diabetes Algorithm [PDF – 258 KB] for common medications and dosing.
  • Supplement calcium if the patient’s calcium level is <8.4 mg/dL.
  • Hold medications that increase calcium if level is >10.2 mg/dL.
  • Treat vitamin D deficiency (25-hydroxy vitamin D level <20 ng/mL) at an early stage of CKD.

Renal Replacement Therapy

It is never too early to begin educating and case managing patients with progressive kidney disease about renal replacement therapy (dialysis or kidney transplantation). See Prepare for Kidney Replacement Therapy Exit Disclaimer: You Are Leaving www.ihs.gov  from NIDDK.

• Consider starting education and conversation early about renal replacement therapy. This conversation may be best initiated in the primary care setting with a trusted health care provider.
• Provide patient education to facilitate self-management and shared decision making about renal replacement therapy.
• Refer patients to a nephrologist for consultation in preparation for renal replacement therapy.