2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S126 Chronic Kidney Disease in Diabetes Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial version of this chapter was written by Philip McFarlane MD FRCPC and Bruce Culleton MD FRCPC KEY MESSAGES • 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. INTRODUCTION Chronic kidney disease (CKD) is one of the most common and potentially devastating complications of diabetes. Fifty percent of people with diabetes have CKD, and CKD associated with diabetes is the leading cause of kidney failure in Canada (1-4). CKD in diabetes can be due to classic diabetic nephropathy or other forms of kidney damage. Classic diabetic nephropathy progresses from subclinical disease to the earliest clinically detectable stage characterized by persistent proteinuria (2,5,6) (Figure 1).The degree of proteinuria is characterized as either microalbuminuria (urinary albumin 30 to 300 mg/day) or overt nephropathy (urinary albumin >300 mg/day) (Table 1). Typically it takes many years to progress through these stages (2,7,8), and significant renal dysfunction is not usually seen until late in the course (9). Because type 2 diabetes can be unrecognized for a long time prior to diagnosis, it is possible for renal disease, including advanced nephropathy, to be present at the time of diagnosis of type 2 diabetes (10,11). Although diabetic nephropathy is common, as many as 50% of people with diabetes and significant renal dysfunction have normal urinary albumin levels with renal disease that is not related to classic diabetic nephropathy (12). For example, hypertensive nephrosclerosis and renovascular disease are common causes of CKD in people with diabetes. Table 2 lists indicators that favour the presence of renovascular disease.The risk of end-stage renal disease in diabetes does not appear to vary significantly whether the kidney disease is related to diabetic nephropathy or alternative renal diagnoses (13). Thus, identification of CKD in diabetes requires screening for proteinuria, as well as an assessment of renal function. Regardless of the cause, the stage of kidney disease can be classified based on the level of renal function (Table 3). In the case of diabetes, the kidney damage associated with stage 1 or 2 CKD manifests as persistent albuminuria (see Screening, p. S127). It is also important to recognize that people with CKD are among those at highest risk for cardiovascular (CV) morbidity and mortality, and that interventions to lower CV risk remain the most important priority in this population (14,15). Figure 1. Stage of diabetic nephropathy by level of urinary albumin by various test methods Urine test Urine dipstick 0 Normal 24-hour 30 mg/day ACR (male) 2.0 mg/mmol ACR (female) 2.8 mg/mmol ACR = albumin to creatinine ratio Stage of nephropathy Microalbuminuria Overt nephropathy (macroalbuminuria) Negative 300 mg/day 20.0 mg/mmol 28.0 mg/mmol Positive Urinary Albumin Level 1000 mg/day 66.7 mg/mmol 93.3 mg/mmol
Table 1. Stages of classic diabetic nephropathy according to urinary albumin level Stage of nephropathy Urine dipstick for protein Urine ACR (mg/mmol) Normal Negative 28.0 (women) >66.7 (men) >93.3 (women) 24- urine collection for albumin* (mg/day) 300 >1000 *Values are for urinary albumin, not total urinary protein, which will be higher than urinary albumin levels. ACR results may be elevated with conditions other than diabetic nephropathy (see text and Table 4) ACR = albumin to creatinine ratio Table 2. Factors favouring the presence of renovascular disease • Severe or refractory hypertension • Low eGFR with normal or near-normal ACR • Low or low-normal serum potassium (especially if patient is on an ACE inhibitor or an ARB) • Flank or abdominal bruits • >30% rise in serum creatinine following initiation of an ACE inhibitor or an ARB • Presence of aortic or peripheral arterial disease • “Flash” pulmonary edema • Asymmetric renal size on ultrasound • Advanced hypertensive retinopathy ACE = angiotensin-converting enzyme ACR = albumin to creatinine ratio ARB = angiotensin II receptor antagonist eGFR = estimated glomerular filtration rate SCREENING Identification of CKD in diabetes is usually a clinical diagnosis, requiring a kidney biopsy only when clinical indicators leave doubt as to the diagnosis. A person with diabetes is considered to have CKD if he or she has classic diabetic nephropathy (as evidenced by persistent albuminuria regardless of level of kidney function), or significantly reduced kidney function (as evidenced by an estimated glomerular filtration rate [eGFR] ≤60 mL/min). Table 4 lists indicators that favour the diagnosis of either diabetic or nondiabetic nephropathy (16-19).As kidney damage is often asymptomatic until severe, screening must be performed to Table 3. Stages of CKD of all types Stage Qualitative description 1 Kidney damage, normal GFR 2 Kidney damage, mildly decreased GFR 3 Moderately decreased GFR 4 Severely decreased GFR CKD = chronic kidney disease eGFR = estimated glomerular filtration rate GFR = glomerular filtration rate eGFR = estimated glomerular filtration rate eGFR (mL/min) ≥90 60–89 30–59 15–29 5 End-stage renal disease 5 years Favours alternate renal diagnosis • Extreme proteinuria (>6 g/day) • Persistent hematuria (microscopic or macroscopic) or active urinary sediment • Rapidly falling eGFR • Low eGFR with little or no proteinuria • Other complications of diabetes not present or relatively not as severe • Known duration of diabetes ≤5 years • Family history of nondiabetic renal disease (e.g. polycystic kidney disease) • Signs or symptoms of systemic disease identify renal damage in order to delay or prevent loss of renal function through early initiation of effective therapies, and to manage complications in those identified with renal disease. In adults, screening is performed by measuring urinary albumin levels and estimating the level of kidney function (Figure 2). S127 COMPLICATIONS AND COMORBIDITIES
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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