NICE guidance - diabetic renal disease in type II diabetes

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Summary points from the guidance include:

Microalbuminuria is the earliest indicator of renal disease (nephropathy) attributable to diabetes. A review of longitudinal studies has shown microalbuminuria to be predictive of total mortality, cardiovascular mortality and cardiovascular morbidity.

  • NICE have stated regarding diabetes and kidney disease (1):
    • testing albumin:creatinine ratio
      • ask all people with or without detected nephropathy to bring in a first-pass morning urine specimen once a year
        • in the absence of proteinuria/urinary tract infection (UTI), send this for laboratory estimation of albumin:creatinine ratio
        • request a specimen on a subsequent visit if UTI prevents analysis
      • make the measurement on a spot sample if a first-pass sample is not provided (and repeat on a first-pass specimen if abnormal) or make a formal arrangement for a first-pass specimen to be provided

    • estimation of glomerular filtration rate
      • measure serum creatinine and estimate the glomerular filtration rate (using the method-abbreviated modification of diet in renal disease [MDRD] four-variable equation) annually at the time of albumin:creatinine ratio estimation

    • diagnosis of microalbuminuria
      • repeat the test if an abnormal albumin:creatinine ratio is obtained (in the absence of proteinuria/UTI) at each of the next two clinic visits but within a maximum of 3-4 months
        • confirmation of microalbuminuria
          • take the result to be confirming microalbuminuria if a further specimen (out of two more) is also abnormal (> 2.5 mg/mmol for men, > 3.5 mg/mmol for women)
    • proteinuria is defined as:
      • albumin:creatinine ratio >30mg/mmol or albumin concentration >200mg/l (1,2) or

      • urine protein:creatinine ratios >45 mg/mmol


    • suspect renal disease other than diabetic nephropathy and consider further investigation or referral when the albumin:creatinine ratio (ACR) is raised and any of the following apply:
      • there is no significant or progressive retinopathy
      • blood pressure is particularly high or resistant to treatment
      • person previously had a documented normal ACR and develops heavy proteinuria (ACR > 100 mg/mmol)
      • significant haematuria is present
      • glomerular filtration rate has worsened rapidly
      • person is systemically ill

    • ACE inhibitor/angiotensin II-receptor antagonist initiation
      • for adults with CKD and diabetes (type 1 or type 2) offer an ARB (angiotensin receptor blocker) or an ACE inhibitor (titrated to the highest licensed dose that the person can tolerate) if ACR (albumin-creatinine ratio) is 3 mg/mmol or more
      • for children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more

    • SGLT2 inhibitors and CKD (2,5)
      • for adults with CKD and type 2 diabetes, offer an SGLT2 inhibitor, in addition to an ARB or an ACE inhibitor at an optimised dose if:
        • ACR is more than 30 mg/mmol, and
        • they meet the criteria in the marketing authorisation (including relevant eGFR thresholds)
        • monitor for volume depletion and eGFR decline
        • in November 2021, not all SGLT2 inhibitors were licensed for this indication
      • for adults with type 2 diabetes and chronic kidney disease who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), consider an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if:
        • ACR is between 3 and 30 mg/mmol and
        • they meet the criteria in the marketing authorisation (including relevant eGFR thresholds)
        • in November 2021, not all SGLT2 inhibitors were licensed for this indication

    • blood pressure target
      • for a person with an abnormal albumin:creatinine ratio, maintain blood pressure below 130/80 mmHg

    • referral criteria
      • agree referral criteria for specialist renal care between local diabetes specialists and nephrologists

Notes:

  • NICE suggest that (2):
    • Do not use reagent strips to identify proteinuria in children and young people

    • Do not use reagent strips to identify proteinuria in adults unless they are capable of specifically measuring albumin at low concentrations and expressing the result as an albumin:creatinine ratio (ACR)

    • For the initial detection of proteinuria in adults, children and young people:
      • use urine ACR rather than protein:creatinine ratio (PCR) because of the greater sensitivity for low levels of proteinuria
      • check an ACR between 3 mg/mmol and 70 mg/mmol in a subsequent early morning sample to confirm the result
      • a repeat sample is not needed if the initial ACR is 70 mg/mmol or more

    • Regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria

    • Measure proteinuria with urine ACR in the following groups:
      • adults, children and young people with diabetes (type 1 or type 2)
      • adults with an eGFR of less than 60 ml/min/1.73 m2
      • adults with an eGFR of 60 ml/min/1.73 m2 or more if there is a strong suspicion of CKD
      • children and young people without diabetes and with creatinine above the upper limit of the age-appropriate reference range

        When ACR is 70 mg/mmol or more, PCR can be used as an alternative to ACR

    Incidental finding of proteinuria on reagent strips

    • If unexplained proteinuria is an incidental finding on a reagent strip, offer testing for CKD using eGFRcreatinine and ACR
      • ACR (albumin creatinine ratio) category ACR (mg/mmol)
        A1 <3
        A2 3-30*
        A3 >30**

        * Relative to young adult level

        ** Including nephrotic syndrome (ACR usually >220 mg/mmol)

Reference:

Last edited 11/2021 and last reviewed 11/2021

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