Screening for micro albuminuria: Measurement of the albumin-to-creatinine ratio in a random spot collection; 24-h collection with creatinine, allowing the simultaneous measurement of creatinine clearance; Timed (e.g., 4-h or overnight) collection. 4/2/2011 11
SCREENING FOR NEPHROPATHY WHEN: Type 1 - annually after puberty and 5 years of DM Type 2 - at diagnosis and then annually WHAT: random urine ACR; and random urine dipstick Suspicion of nondiabetic renal disease? Yes Workup or referral for nondiabetic renal disease No Normal < 2.0 mg/mmol men < 2.8 mg/mmol women Rescreen in 1 year Macroalbuminuria > 20 mg/mmol men > 28 mg/mmol women Diabetic nephropathy diagnosed Check ACR results Microalbuminuria 2.0 - 20 mg/mmol men 2.8 - 28 mg/mmol women Any 2 abnormal out of 3 ACRs: Diabetic nephropathy diagnosed Up to 2 repeat random urine ACRs performed 1 week to 2 months apart Only 1 abnormal ACR: Repeat screen in 1 year 4/2/2011 12
Patients starting therapy with an ACE inhibitor or ARB should be monitored at 1 to 2 weeks for significant worsening of kidney function or the development of significant hyperkalemia. Serum creatinine typically rises up to 30% above baseline after initiating an ACE inhibitor or ARB, and usually stabilizes after 2 to 4 weeks.
Patients who develop mild to moderate hyperkalemia should receive nutritional counseling regarding a potassium-sparing diet and consideration should be given to the use of non-potassium-sparing diuretics.
Second-line renal protective agents (non-dihydropyridine calcium channel blockers) can be considered in those unable to tolerate an ACE inhibitor or an ARB.
TREATMENT OF NEPHROPATHY Choose 2nd line therapy: ACE + ARB or add non-DHP CCB YES Already on ACE inhibitor? NO YES On first-line nephropathy drug? YES First line drug at maximum dose? NO NO NO Add first-line drug; Recheck ACR in 2 weeks to 2 months Titrate up; recheck ACR in 2 weeks to 2 months ACR normal? Yes Remeasure ACR in 1 year First line drugs: Type 1- ACE inhibitor Type 2 with Cr Cl > 60 mL/min - ACE inhibitor or ARB Type 2 with Cr Cl 60 mL/min - ARB 4/2/2011 16