2.30 Conditions to Consider at Diabetes Planned Visit

2.30 Conditions to Consider at Diabetes Planned Visit

Diabetes planned visits address several health topics of concern to the diabetic patient, including kidney function. This document provides an overview of microalbuminuria and diabetic nephropathy, tests available to detect them, and advice on treating them.

Microalbuminuria

  • Term distinguishes incipient nephropathy from overt nephropathy and macroalbuminuria.
  • It is not 'small albumin,' but albumin excretion undetected by dip U/A.
  • Very sensitive indicator of early glomerular damage.

Diabetic Nephropathy

  • 30-299 mcg albumin/mg creatinine.
  • 30-299 mg albumin /24 hour collection.
  • Test should be confirmed X1
    • and note made of factors that may increase protein excretion.
  • Once diagnosed, follow with 24 hr protein excretion.

Specimen collection

  • 24 hour urine is the gold standard.
    • Incomplete 24 hr specimen better than one spot urine/creatinine ratio.
  • Spot urine/creatinine ratio:
    • PM 2X higher than AM.
    • Creatinine excretion varies independent of protein (e.g., heavy exercise).

Avoid microalbumin screening when:

  • UTI.
  • Hematuria.
  • Febrile illness.
  • Vigorous exercise.
  • Short term severe hyperglycemia.
  • BP uncontrolled (>160/95 ?).
  • Heart failure.

Why worry about protein?

  • Proteinuria is nephrotoxic in and of itself.
  • Reducing proteinuria slows decline in GFR.

Preserving Renal Function

Level I recommendations

  • Systolic BP <120mmHg.
  • Maximum recommended ACE dose.
  • Maximum recommended ARB dose.
  • ACE plus ARB.
  • Avoid dihydropyridine CCBs.
  • Use beta blockers (BB).
    • Preferred over DHCCB.

Level II recommendations

  • Glycemic control (HgbA1c <7).
  • Stop smoking.
  • Statin to achieve LDL <100, or <70.
  • Aspirin.
  • Limit sodium to 2-3 grams/day.
  • Chicken instead of red meat?

BP Control Strategies

  • ACE, then diuretic, then ARB.
  • If not a goal confirm:
    • Proper BP measurement.
    • Medication adherence.
    • Low sodium.
    • Avoid EtOH >2 oz/day, NSAID, decongestants, high dose estrogen.

Plan B for BP control

  • ACE + ARB + diuretic + BB.
  • ACE + ARB + diuretic + NDH-CCB.
  • ACE + ARB+ diuretic + clonidine.
  • Ace + ARB + diuretic + alpha 1 blocker.

Plan C for BP control

  • Increase diuretic, consider furosemide.
  • ACE + ARB + diuretic + BB + DH-CCB.
  • ACE + ARB + diuretic +BB +minoxidil.
  • ACE + ARB + diuretic + NDH-CCB + DH-CCB.
  • ACE + ARB +diuretic + BB + alpha 1 blocker.
  • ACE + ARB + diuretic + BB + clonidine.

ACE worries

  • OK if creatinine >3 mg/dl.
  • Serum creatinine rises up to 50% OK if no further increase.

Safety of ACE + ARB

  • Only decrease BP 4.5/2.5 mmHg.
  • Small increase in K+.
  • Slight decrease in GFR.
  • Proteinuria improves.

Rap against DH-CCBs

  • Not anti-proteinuric.
  • Worsen proteinuria despite BP control
    • Amlodipine (Norvasc), nislodpine.
  • AASK trial
    • DH CCB increased risk of doubling of creatinine, ESRD, death vs ACE or BB.
Current as of January 2008
Internet Citation: 2.30 Conditions to Consider at Diabetes Planned Visit: 2.30 Conditions to Consider at Diabetes Planned Visit. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk230.html