Management of diabetic renal disease - New Zealand Society for the Study of Diabetes

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Home Screening and management of complications of diabetes Management of diabetic renal disease

Type 2 Diabetes Management Guidelines

Management of diabetic renal disease

Diabetic renal disease is the most common cause of chronic renal failure, but be aware of red flags for alternative causes of renal dysfunction

Consider investigation +/- referral for all patients with atypical features

Red flags for alternative causes of renal dysfunction in patients with diabetes

Short duration of diabetes e.g. < 5 years
Young patients e.g. < 30 years of age
Persistent decline in eGFR > 1 mL/min per month or > 10 mL/min per year (NB: eGFR is hydration dependent)
No evidence of diabetic retinopathy
Family history of renal disease
Overt features of alternative cause e.g. connective tissue disease, recurrent UTIs, hypertension, casts on MSU

The first sign of diabetic renal disease is typically microalbuminuria , but many patients with diabetes develop renal impairment without proteinuria

Microalbuminuria is defined as more than two urinary albumin:creatinine ratios (ACR) in a greater than 3 month period of > 2.5 mg/mmol in males and > 3.5 mg/mmol in females

Two positive samples are required to exclude falsely raised ratios due to:

UTI
Intercurrent illness
Vigorous physical activity
Haematuria
Significant hyperglycaemia

Macroalbuminuria is defined as a urinary ACR > 30 mg/mmol

Major factors that reduce progression of renal disease:

Effective glycaemic control
SGLT2 inhibitors + GLP1RA (benefits independent of glucose lowering effects and renin-angiotensin-aldosterone system blockade)
Effective treatment of hypertension
Blockade of renin-angiotensin-aldosterone system e.g. ACE inhibitors (ACEi), angiotensin receptor blocker (ARB) and spironolactone (benefits independent of blood pressure lowering effects)
Smoking cessation

If microalbuminuria or decline in eGFR is present then:

Lifestyle management and optimising glycaemic control
Manage hypertension aggressively with ACEi or ARB if no contraindication (do not use in combination without specialist opinion or do not use either if on Entresto) then spironolactone

In women of childbearing age ensure adequate contraception + not pregnant before starting
Repeat eGFR and potassium 7-10 days after starting

If > 25% reduction in eGFR reduce or stop the ACEi/ARB and consider renal artery stenosis
If potassium > 6 mmol/L reduce or stop the ACEi/ARB/Spirinolactone

Strongly consider starting an SGLT2 inhibitor and/or GLP1 receptor agonist
Treat dyslipidaemia and advise smoking cessation
Monitor serum eGFR and potassium levels and urinary ACR 3-6 monthly
Review medication regimen if declining eGFR:

Metformin dose should be reduced when eGFR < 60 mL/min
Doses of insulin and sulfonylureas may need to be reduced as insulin is renally cleared + gluconeogenesis will be reduced

Consider referring to Renal team as per local DHB policy

eGFR < 30 mL/min
Decline in eGFR by > 15 mL/min/year
Decline in eGFR by > 25% with ACEi or ARB
Significant proteinuria
Persistent red flags for alternative causes of renal dysfunction