CHICAGO — Guidelines developed for the first time by the Kidney Disease Outcomes Quality Initiative provide detailed information on how to improve clinical outcomes in patients who have both diabetes and chronic kidney disease, Dr. Robert Nelson said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.
The guidelines emphasize tight control of glucose, blood pressure, and lipids, along with frequent monitoring of urinary protein in patients with this dual condition. Dr. Nelson of the National Institutes of Health in Phoenix offered a preview of the guidelines, which will be published in the American Journal of Kidney Diseases this fall.
The Kidney Disease Outcomes Quality Initiative guidelines recommend that people with type 1 diabetes undergo screening for diabetic kidney disease 5 years after diagnosis, and then annually. In type 2 diabetics, annual screening should begin at diagnosis.
Primary care physicians can easily follow these guidelines by obtaining spot urine samples for an albumin/creatinine ratio—at least two samples within 3 months, Dr. Nelson noted.
If the urine albumin/creatinine ratio exceeds 300 mg/g, a number that is consistent with macroalbuminuria, then the physician can diagnose diabetic kidney disease without doing a renal biopsy.
In addition, patients with microalbuminuria who also have retinopathy are considered to have diabetic kidney disease.
Clues to the diagnosis of nondiabetic kidney disease in diabetic patients include lack of diabetic nephropathy, a rapid decrease in glomerular filtration rate, and sudden onset of nephropathy.
Solid research evidence shows that the cornerstone of managing patients with diabetic kidney disease is maintaining a target hemoglobin A1c of 7% or below, Dr. Nelson said, citing the Diabetes Control and Complications Trial (N. Engl. J. Med. 1993;329:977–86).
Physicians must also manage hypertension aggressively in patients with diabetic kidney disease. Both ACE inhibitors and angiotensin-receptor blockers (ARBs), often given with a diuretic, can help patients achieve the goal blood pressure of 130/80 mm Hg or lower.
“We believe that the efficacy of ACE inhibitors and ARBs are similar,” Dr. Nelson said.
Achieving the blood pressure goal is a very important preventive measure, and clinicians can use additional classes of antihypertensive medication as needed to meet this goal.