2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S130
RECOMMENDATIONS
1.The best possible glycemic control and, if necessary, intensive
diabetes management should be instituted in people
with type 1 or type 2 diabetes for the prevention of onset
and delay in progression to CKD [Grade A, Level 1A
(34,71,72)].
2. In adults, screening for CKD in diabetes should be conducted
using a random ACR and a serum creatinine converted
into an eGFR [Grade D, Consensus]. Screening
should be performed annually in adults with type 1 diabetes
of >5 years’ duration. Individuals with type 2 diabetes
should be screened at diagnosis of diabetes and
yearly thereafter. Screening should be delayed when causes
of transient albuminuria or low eGFR are present
[Grade D, Consensus].
3. People with diabetes and CKD should have a random
urine ACR and a serum creatinine converted into an eGFR
performed at least every 6 months [Grade D, Consensus].
4.Adults with diabetes and persistent albuminuria (ACR
>2.0 mg/mmol in males, >2.8 mg/mmol in females) should
receive an ACE inhibitor or an ARB to delay progression
of CKD, even in the absence of hypertension [Grade A,
Level 1A (37,39-42,47,48,50,51,73), 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].
5. People with diabetes on an ACE inhibitor or an ARB
should have their serum creatinine and potassium levels
checked within 1 to 2 weeks of initiation or titration of
ney or severe bilateral disease (62,63). However, serum
creatinine and potassium levels should be monitored carefully
if these medications are used when renovascular disease
is suspected (64).
Individuals who develop mild to moderate hyperkalemia
should receive nutritional counselling regarding a potassiumrestricted
diet, and consideration should be given to the use
of nonpotassium-sparing diuretics (such as thiazides or
furosemide). If an ACE inhibitor or ARB is not tolerated due
to severe hyperkalemia, or >30% increase in serum creatinine
or allergic reactions, the drug should be withdrawn and other
ACE inhibitors or ARBs should not be substituted.
To avoid acute renal failure, ACE inhibitors, ARBs and
diuretics should be stopped during acute illnesses associated
with intravascular volume contraction. There is no upper
limit of the serum creatinine level for initiation of ACE
inhibitor or ARB therapy, but if the creatinine clearance is
30% increase in serum
creatinine within 3 months of starting an ACE inhibitor
or ARB [Grade D, Consensus].
should be given to stopping these drugs prior to conception.
Individuals started on a non-DHP CCB should be monitored
clinically for development of bradycardia. As all
nephroprotective drugs are also antihypertensives, individuals
should be monitored for development of hypotension.
The role of proteinuria reduction
The amount of proteinuria correlates with the likelihood of
progression of many kidney diseases, including diabetic
nephropathy (66-69). Individuals with an antiproteinuric
response to an ACE inhibitor or an ARB are less likely to
progress to renal failure (66).These findings, in combination
with basic science evidence (70), suggest that proteinuria
may contribute to kidney damage, and many clinicians now
target proteinuria for reduction independent of BP level.
However, no large-scale hard-endpoint trials in which proteinuria
reduction was the primary intervention have been
completed, and the role of proteinuria as a causative factor in
renal damage remains controversial. Which populations
should be targeted for reduction of proteinuria, the thresholds
and targets for antiproteinuric therapies, and the optimal
antiproteinuric drug regimens remain topics of active
research. While reduction of proteinuria in diabetic
nephropathy may be desirable, it is not possible to generate a
clinical practice guideline in this area at this time.