Approach to Chronic Kidney Disease in the Diabetic Patient

The diagnosis of diabetic kidney disease (DKD) is generally made clinically, either by increased urinary albumin excretion (>30mg/day) or declining glomerular filtration rate, usually in the presence of diabetic retinopathy. All diabetic patients should undergo annual measurements of serum creatinine concentration (S[Cr]) and urinary albumin concentration and have their estimated glomerular filtration rate (eGFR) calculated. Control of blood glucose to achieve an HbA1c of 7%, and blood pressure aimed at a level less than 130/80mmHg, as tolerated, can delay or prevent onset of DKD. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are first-line treatments in hypertensive and nonhypertensive DKD patients, especially those with increased urinary albumin excretion. The use of sodium-glucose cotransporter 2 inhibitors also prevents DKD progression in patients with both preserved and decreased eGFR. 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 renal replacement therapy (RRT) by a nephrologist. Proper candidates should be prepared for end-stage renal disease therapy by discussing modalities of RRT, including renal transplantation, providing necessary education, creating dialysis access when appropriate, and making necessary referrals.