DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

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L. Management of Kidney Disease in Diabetes Mellitus
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
For complete management of Chronic Kidney Disease (CKD) see: VA/DoD Clinical Practice Guideline for the
Diagnosis and Management of Chronic Kidney Disease at http://www.healthquality.va.gov/ or
http://www.qmo.amedd.army.mil
BACKGROUND
Twenty-five to 45 percent of patients with type 1 and type 2 DM will develop diabetic nephropathy. Clinical
evidence for nephropathy, manifested by microalbuminuria, proteinuria, and reduced kidney function, can be seen 5
to 20 years after the development of DM. Generally, nephropathy steadily progresses until the patient requires
dialysis or a kidney transplant. However, progressive kidney failure can be prevented or delayed through early
intervention and appropriate management. Patients with nephropathy have a very high cardiovascular risk and
should undergo appropriate screening and prevention if life expectancy is not already limited by co-morbid
conditions (e.g., metastatic cancer and severe Chronic Obstructive Pulmonary Disease).
CKD is defined as the presence of decreased eGFR or proteinuria, which can occur together or independently, or the
presence of microalbuminuria in patients with diabetes or structural kidney disease. The presence of proteinuria may
indicate kidney disease even with a normal eGFR. Any of these patients has kidney disease that might progress to
kidney failure.
Patients with diabetes who develop nephropathy are referred in this guideline as having chronic kidney disease
(CKD) and should be managed according to the VA/DoD Clinical Practice Guideline for Chronic Kidney Disease.
RECOMMENDATIONS
SCREENING FOR CKD
1. Patients with, diabetes, should be screened periodically for the presence of kidney disease. [C]
2. Testing for kidney disease includes urinalysis and estimation of the glomerular filtration rate (eGFR). [B]
3. Patients with diabetes who have a negative urine protein by dipstick should be tested for the presence of
microalbuminuria. [B]
4. Definitions of Chronic Kidney Disease includes any of the following:
a. Persistent decreased eGFR < 60 ml/min/1.73m2 on two tests at least three months apart
b. Proteinuria (> 1+) on dipstick or urine protein-to-creatine ratio > 0.2, confirmed on two tests at
least three months apart
c. Microalbuminuria defined as albumin-to-creatine ratio > 30, confirmed on two out of three urine
tests in patients with diabetes mellitus (DM)
d. Known structural kidney disease defined by imaging or pathologic examination (e.g., polycystic
kidney disease [PCKD])
e. Estimated glomerular filtration rate (eGFR) is the preferred method to assess kidney function.
5. The severity of CKD should be classified based on the level of the glomerular filtration rate (GFR) (see
Table D-9). Kidney function should be assessed by formula-based estimation of GFR (eGFR), preferably
using the 4-variable Modification of Diet in Renal Disease (MDRD) equation. [A]
SCREENING for PROTEINURIA
6. Microalbuminuria – in patients with diabetes – should be assessed using a laboratory method expressed as
an albumin-to-creatinine ratio. If dipsticks designed to detect urinary microalbumin are used, positive tests
should be followed by laboratory confirmation.
7. The diagnosis of microalbuminuria cannot be reliably made in the presence of an acute medical condition.
As far as it is practicable, the best possible metabolic control of diabetes should be achieved before
evaluating for microalbuminuria. Patients should not be screened during intercurrent illness or after heavy
exercise.
8. It is important to consider other causes of increased albumin excretion, especially in the case of Type 1
Module D: Core Page 28