Royal Free London NHS Foundation Trust
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Diabetes guidelines

  1. Diagnosis and Classification of Diabetes
  2. Initial Assessment and Criteria for Specialist Referral
  3. Glycaemic Control in Type 2 Diabetes - Oral Hypoglycaemic Agents
  4. Indications for Insulin in Type 2 Diabetes
  5. Hypertension
  6. Dyslipidaemia
  7. Aspirin Therapy in Diabetes
  8. Retinopathy
  9. Nephropathy
  10. Neuropathy and Foot Ulcers
  11. Sexual Dysfunction in Men
  12. Diabetes in Pregnancy and Pre-conception Guidance

9. Nephropathy

- Please also refer to NICE Guideline F: Management of Type 2 Diabetes - Renal Disease, prevention and early management

The risk of nephropathy is roughly equivalent in type 1 and type 2 diabetes. The earliest clinical manifestation of diabetic renal disease is microalbuminuria, a stage at which renal histology may be relatively normal or may reveal evidence of glomerulosclerosis. Although blood pressure control is important in type 2 diabetes, it remains unclear if ACE inhibitors have the same preferential renoprotective effect in this disorder. More data are currently available on the efficacy of angiotensin receptor blockers (ARBs). Strict blood pressure control is clearly important for preventing progression of diabetic complications in general as well as the nephropathy. In UKPDS, each 10mmHg reduction in systolic pressure was associated with a 12 percent risk reduction in diabetic complications (P<0.001); the lowest risk occurred at a systolic pressure below 120mmHg.

Hyperlipidaemia is common in diabetic patients, a tendency that is increased by the development of renal insufficiency. In addition to promoting systemic atherosclerosis, an elevation in lipid levels also may contribute to the development of glomerulosclerosis in chronic renal failure. There is also preliminary evidence that lipid lowering may have a beneficial effect on renal function.

It has been recommended that the urine albumin:creatinine ratio on a first morning sample and serum creatinine be measured on an annual basis. Patients with higher-risk albumin excretion are those with microalbuminuria (defined as an albumin:creatinine ratio = 2.5mg/mmol in men and 3.5mg/mmol in women) and proteinuria (defined as an albumin:creatinine ratio = 30mg/mmol). If higher-risk urine albumin excretion is present then the following are recommended:

  1. If retinopathy not present, consider non-diabetes-related cause of renal disease
  2. Ensure good blood glucose control (HbA1c 6.5-7.5%)
  3. Manage cardiovascular risk factors aggressively
  4. Maintain BP below 135/75
  5. Begin therapy with an appropriate ACE inhibitor for cardiovascular and renal protection. Combination therapy is likely to be required in most patients.
  6. Care with ACE inhibitors is required in the presence of peripheral vascular disease or raised serum creatinine. Serum creatinine and electrolytes 1 week after initiating therapy.
  7. Refer for specialist nephrology opinion if serum creatinine >150┬Ámol/L
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page last reviewed: 11 June 2008