Synopsis
Identify diabetic kidney disease from albuminuria and filtration trends, exclude important alternative diagnoses, and combine renal, cardiovascular and glycaemic protection without provoking acute kidney injury or hyperkalaemia.
- Screen diabetic kidney disease with both estimated glomerular filtration rate and urine albumin-to-creatinine ratio because either may be abnormal while the other remains apparently normal.
- Confirm a new moderately raised albumin-to-creatinine ratio on an early-morning sample after excluding urinary infection, menstruation, fever, strenuous exercise and acute decompensation.
- Diabetes is not proof of causation: haematuria, abrupt filtration loss, nephrotic syndrome, systemic features or an atypical time course should prompt investigation for non-diabetic kidney disease.
Key red flags
Visible or persistent microscopic haematuria, active urine sediment, abrupt creatinine rise, rapid eGFR loss, nephrotic syndrome or systemic inflammation suggests another or additional renal disorder.
Investigation priorities
Quantify albumin loss and assign the albuminuria component of CKD risk.
Management branches
Routine diabetes review identifies an abnormal urine albumin-to-creatinine ratio, eGFR or creatinine trend.
- Check prior results, volume status, acute illness, urinary infection, recent exercise, medicines and blood pressure to distinguish chronic disease from a transient or acute change.
- Repeat albuminuria using the recommended early-morning strategy and establish eGFR chronicity, while obtaining urinalysis and targeted tests for atypical features.
Key medicines
ACE inhibitorStart at a low licensed dose and titrate toward the maximum tolerated dose with laboratory monitoring.
Angiotensin receptor blockerUse a licensed once-daily regimen and titrate with blood pressure, creatinine and potassium review.