Approach to Chronic Kidney Disease in the Diabetic Patient

The diagnosis of diabetic kidney disease (DKD) is made clinically, either by increased urinary albumin excretion (>30. mg/day) or declining GFR, usually in the presence of diabetic retinopathy. All diabetic patients should undergo annual measurements of S[Cr], urinary albumin, and have an eGFR calculated. Control of blood sugar to achieve an HbA1c of 7%, and blood pressure aimed at a level less than 140/90. mm. Hg can delay or prevent onset of DKD. ACEIs and ARBs are first-line treatments in hypertensive and non-hypertensive DKD patients, especially those with increased urinary albumin excretion. Lipid lowering therapy is beneficial in the primary prevention of cardiovascular events in DKD patients. Dietary protein restriction should also be considered for DKD patients. All patients with stage 4 or 5 CKD should be evaluated for potential RRT. Proper candidates should be prepared for ESRD therapy by discussing modalities of RRT, including renal transplantation, providing necessary education, creating dialysis access when appropriate and making necessary referrals.