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Chronic Kidney Disease in Diabetes
Can J Diabetes 37 (2013) S329eS331
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Executive Summary
Chronic Kidney Disease in Diabetes
KEY MESSAGES RECOMMENDATIONS Identification of chronic kidney disease (CKD) in diabetes requires screening for proteinuria, as well as an assessment of renal function. All individuals with CKD should be considered at high risk for cardiovascular events and should be treated to reduce these risks. The progression of renal damage in diabetes can be slowed through intensive glycemic control and optimization of blood pressure. Progression of diabetic nephropathy can be slowed through the use of medications that disrupt the renin-angiotensin-aldosterone system.
1. In adults, screening for CKD in diabetes 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. A diagnosis of CKD should be made in patients with a random urine ACR 2.0 mg/mmol and/or an eGFR<60 mL/min on at least 2 of 3 samples over a 3-month period [Grade D, Consensus]. 2. All patients with diabetes and CKD should receive a comprehensive, multifaceted approach to reduce cardiovascular risk (see Vascular Protection chapter, p. S322) [Grade A, Level 1A (1,2)].
Highlights of Revisions The chapter includes a new, simplified definition of microalbuminuria of albumin to creatinine ratio (ACR) 2.0 mg/mmol for both men and women (Table 1 and Table 2). The chapter includes a new algorithm for screening for chronic kidney disease in adults (Figure 1). Added a “Sick Day Management” list for acute illness (p. S357).
3. 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; Grade D, Consensus, for ARB use in type 1 diabetes (3e12)]. 4. 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].
PRACTICAL TIPS Management of Potassium and Creatinine During Use of an Angiotensin-Converting Enzyme (ACE) Inhibitor, Angiotensin II Receptor Blocker (ARB) or Direct Renin Inhibitor (DRI) 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. If potassium becomes elevated or creatinine increases by more than 30% from baseline, therapy should be reviewed and serum creatinine and potassium levels should be rechecked. Mild-to-moderate stable hyperkalemia: B Counsel on a low-potassium diet. B If persistent, nonepotassium-sparing diuretics and/or oral sodium bicarbonate (in those with a metabolic acidosis) should be considered. B Consider temporarily holding renin-angiotensin-aldosterone system (RAAS) blockade (i.e. ACE inhibitor, ARB or DRI). Severe hyperkalemia: B In addition to emergency management strategies, RAAS blockade should be held or discontinued.
1499-2671/$ e see front matter Ó 2013 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2013.02.029
5. Adults with diabetes and CKD should be given a “sick day” medication list that outlines which medications should be held during times of acute illness (see Appendix 7) [Grade D, Consensus]. 6. Combination of agents that block the renin-angiotensin-aldosterone system (ACE inhibitor, ARB, DRI) should not be routinely used in the management of diabetes and CKD [Grade A, Level 1 (13,14)]. 7. People with diabetes should be referred to a nephrologist or internist with an expertise in CKD in the following situations: a. Chronic, progressive loss of kidney function b. ACR persistently >60 mg/mmol c. eGFR< 30 mL/min d. Unable to remain on renal-protective therapies due to adverse effects such as hyperkalemia or >30% increase in serum creatinine within 3 months of starting an ACE inhibitor or ARB e. Unable to achieve target blood pressure (could be referred to any specialist in hypertension) [Grade D, Consensus] Abbreviations: ACE, angiotensin-converting enzyme; ACR, albumin-to-creatinine ratio; ARB, angiotensin II receptor block; CKD, chronic kidney disease; DRI, direct renin inhibitor; eGFR, estimated glomerular filtration rate.
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Executive Summary / Can J Diabetes 37 (2013) S329eS331
Table 1 Stages of Diabetic Nephropathy by Level of Urinary Albumin Level
Please note, Table 4 listed in the above table can be viewed in the full 2013 guidelines.
Table 2 Conditions that can cause transient albuminuria
References 1. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383e93. 2. Gaede P, Lund-Andersen H, Parving HH, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580e91. 3. Lewis EJ, Hunsicker LG, Bain RP, et al. The effect of angiotensin-convertingenzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med 1993;329:1456e62. 4. Strippoli GF, Craig MC, Schena FP, et al. Role of blood pressure targets and specific antihypertensive agents used to prevent diabetic nephropathy and delay its progression. J Am Soc Nephrol 2006;17:S153e5.
5. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345:851e60. 6. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345:861e9. 7. Parving HH, Lehnert H, Brochner-Mortensen J, et al. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001;345:870e8. 8. Laffel LM, McGill JB, Gans DJ. The beneficial effect of angiotensin-converting enzyme inhibition with captopril on diabetic nephropathy in normotensive IDDM patients with microalbuminuria. North American Microalbuminuria Study Group. Am J Med 1995;99:497e504. 9. ACE Inhibitors in Diabetic Nephropathy Trialist Group. Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data. Ann Intern Med 2001;134:370e9. 10. Ravid M, Savin H, Jutrin I, et al. Long-term stabilizing effect of angiotensinconverting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann Intern Med 1993;118: 577e81. 11. Mathiesen ER, Hommel E, Hansen HP, et al. Randomised controlled trial of long term efficacy of captopril on preservation of kidney function in normotensive patients with insulin dependent diabetes and microalbuminuria. BMJ 1999;319:24e5. 12. Viberti G, Wheeldon NM. Microalbuminuria reduction with valsartan in patients with type 2 diabetes mellitus: a blood pressure-independent effect. MicroAlbuminuria Reduction With VALsartan Study Investigators. Circulation 2002;106:672e8. 13. Tobe SW, Clase CM, Gao P, et al. Cardiovascular and renal outcomes with telmisartan, ramipril, or both in people at high renal risk: results from the ONTARGET and TRANSCEND studies. Circulation 2011;123:1098e107. 14. Parving H, Brenner BM, McMurray JJV, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med 2012;367:2204e13.
Executive Summary / Can J Diabetes 37 (2013) S329eS331
Figure 1. Screening for chronic kidney disease in people with diabetes. Please note, Table 4 listed in the above figure can be viewed in the full 2013 guidelines.
S331
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Executive Summary
Chronic Kidney Disease in Diabetes
KEY MESSAGES RECOMMENDATIONS Identification of chronic kidney disease (CKD) in diabetes requires screening for proteinuria, as well as an assessment of renal function. All individuals with CKD should be considered at high risk for cardiovascular events and should be treated to reduce these risks. The progression of renal damage in diabetes can be slowed through intensive glycemic control and optimization of blood pressure. Progression of diabetic nephropathy can be slowed through the use of medications that disrupt the renin-angiotensin-aldosterone system.
1. In adults, screening for CKD in diabetes 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. A diagnosis of CKD should be made in patients with a random urine ACR 2.0 mg/mmol and/or an eGFR<60 mL/min on at least 2 of 3 samples over a 3-month period [Grade D, Consensus]. 2. All patients with diabetes and CKD should receive a comprehensive, multifaceted approach to reduce cardiovascular risk (see Vascular Protection chapter, p. S322) [Grade A, Level 1A (1,2)].
Highlights of Revisions The chapter includes a new, simplified definition of microalbuminuria of albumin to creatinine ratio (ACR) 2.0 mg/mmol for both men and women (Table 1 and Table 2). The chapter includes a new algorithm for screening for chronic kidney disease in adults (Figure 1). Added a “Sick Day Management” list for acute illness (p. S357).
3. 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; Grade D, Consensus, for ARB use in type 1 diabetes (3e12)]. 4. 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].
PRACTICAL TIPS Management of Potassium and Creatinine During Use of an Angiotensin-Converting Enzyme (ACE) Inhibitor, Angiotensin II Receptor Blocker (ARB) or Direct Renin Inhibitor (DRI) 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. If potassium becomes elevated or creatinine increases by more than 30% from baseline, therapy should be reviewed and serum creatinine and potassium levels should be rechecked. Mild-to-moderate stable hyperkalemia: B Counsel on a low-potassium diet. B If persistent, nonepotassium-sparing diuretics and/or oral sodium bicarbonate (in those with a metabolic acidosis) should be considered. B Consider temporarily holding renin-angiotensin-aldosterone system (RAAS) blockade (i.e. ACE inhibitor, ARB or DRI). Severe hyperkalemia: B In addition to emergency management strategies, RAAS blockade should be held or discontinued.
1499-2671/$ e see front matter Ó 2013 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2013.02.029
5. Adults with diabetes and CKD should be given a “sick day” medication list that outlines which medications should be held during times of acute illness (see Appendix 7) [Grade D, Consensus]. 6. Combination of agents that block the renin-angiotensin-aldosterone system (ACE inhibitor, ARB, DRI) should not be routinely used in the management of diabetes and CKD [Grade A, Level 1 (13,14)]. 7. People with diabetes should be referred to a nephrologist or internist with an expertise in CKD in the following situations: a. Chronic, progressive loss of kidney function b. ACR persistently >60 mg/mmol c. eGFR< 30 mL/min d. Unable to remain on renal-protective therapies due to adverse effects such as hyperkalemia or >30% increase in serum creatinine within 3 months of starting an ACE inhibitor or ARB e. Unable to achieve target blood pressure (could be referred to any specialist in hypertension) [Grade D, Consensus] Abbreviations: ACE, angiotensin-converting enzyme; ACR, albumin-to-creatinine ratio; ARB, angiotensin II receptor block; CKD, chronic kidney disease; DRI, direct renin inhibitor; eGFR, estimated glomerular filtration rate.
S330
Executive Summary / Can J Diabetes 37 (2013) S329eS331
Table 1 Stages of Diabetic Nephropathy by Level of Urinary Albumin Level
Please note, Table 4 listed in the above table can be viewed in the full 2013 guidelines.
Table 2 Conditions that can cause transient albuminuria
References 1. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383e93. 2. Gaede P, Lund-Andersen H, Parving HH, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580e91. 3. Lewis EJ, Hunsicker LG, Bain RP, et al. The effect of angiotensin-convertingenzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med 1993;329:1456e62. 4. Strippoli GF, Craig MC, Schena FP, et al. Role of blood pressure targets and specific antihypertensive agents used to prevent diabetic nephropathy and delay its progression. J Am Soc Nephrol 2006;17:S153e5.
5. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345:851e60. 6. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345:861e9. 7. Parving HH, Lehnert H, Brochner-Mortensen J, et al. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001;345:870e8. 8. Laffel LM, McGill JB, Gans DJ. The beneficial effect of angiotensin-converting enzyme inhibition with captopril on diabetic nephropathy in normotensive IDDM patients with microalbuminuria. North American Microalbuminuria Study Group. Am J Med 1995;99:497e504. 9. ACE Inhibitors in Diabetic Nephropathy Trialist Group. Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data. Ann Intern Med 2001;134:370e9. 10. Ravid M, Savin H, Jutrin I, et al. Long-term stabilizing effect of angiotensinconverting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann Intern Med 1993;118: 577e81. 11. Mathiesen ER, Hommel E, Hansen HP, et al. Randomised controlled trial of long term efficacy of captopril on preservation of kidney function in normotensive patients with insulin dependent diabetes and microalbuminuria. BMJ 1999;319:24e5. 12. Viberti G, Wheeldon NM. Microalbuminuria reduction with valsartan in patients with type 2 diabetes mellitus: a blood pressure-independent effect. MicroAlbuminuria Reduction With VALsartan Study Investigators. Circulation 2002;106:672e8. 13. Tobe SW, Clase CM, Gao P, et al. Cardiovascular and renal outcomes with telmisartan, ramipril, or both in people at high renal risk: results from the ONTARGET and TRANSCEND studies. Circulation 2011;123:1098e107. 14. Parving H, Brenner BM, McMurray JJV, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med 2012;367:2204e13.
Executive Summary / Can J Diabetes 37 (2013) S329eS331
Figure 1. Screening for chronic kidney disease in people with diabetes. Please note, Table 4 listed in the above figure can be viewed in the full 2013 guidelines.
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