What is the management plan for a patient with normal Blood Urea Nitrogen (BUN), creatinine, and estimated Glomerular Filtration Rate (eGFR)?

Management of Patients with Normal BUN, Creatinine, and eGFR

For patients with diabetes and normal kidney function markers (BUN, creatinine, eGFR), continue annual screening with UACR and eGFR, optimize glycemic control (HbA1c <7% for most patients), maintain blood pressure <130/80 mmHg, and do not initiate ACE inhibitors or ARBs solely for kidney protection. 1

Screening and Monitoring Strategy

• Perform annual screening with both urine albumin-to-creatinine ratio (UACR) and eGFR measurement in all patients with type 2 diabetes at diagnosis and annually thereafter 1
• For type 1 diabetes patients, begin screening within 5 years of diagnosis 1
• Use spot urine samples (preferably early morning) to calculate UACR rather than 24-hour collections 1
• Normal UACR is defined as <30 mg/g creatinine 1

Key caveat: Two of three UACR specimens collected within 3-6 months should be abnormal before diagnosing albuminuria, due to biological variability exceeding 20% between measurements 1

Risk Factor Optimization

Glycemic Control

• Target HbA1c <7.0% for most patients to reduce risk of developing diabetic kidney disease 1
• Consider individualized targets: <6.5% for younger patients without hypoglycemia risk, or <8.0% for those with high hypoglycemia risk or multiple comorbidities 1
• Intensive glucose management has been demonstrated in large prospective randomized studies to delay onset of kidney disease 1

Blood Pressure Management

• **Target blood pressure <130/80 mmHg** for patients with 10-year ASCVD risk >15% 1
• Target <140/90 mmHg acceptable for those with 10-year ASCVD risk <15% 1
• More aggressive targets (systolic <120 mmHg) may be appropriate for adults with type 2 diabetes at high cardiovascular risk 1

Medication Considerations

• Do NOT initiate ACE inhibitors or ARBs in patients with normal blood pressure, normal UACR (<30 mg/g), and normal eGFR, as they are not recommended for primary prevention 1
• This represents a critical pitfall: ACE inhibitors/ARBs should only be started when albuminuria develops or blood pressure requires treatment 1

Dietary Recommendations

• Maintain protein intake at approximately 0.8 g/kg/day (the recommended daily allowance based on ideal body weight) 1
• Reducing protein below this level does not alter glycemic measures, cardiovascular risk, or prevent kidney disease development 1

When to Escalate Monitoring

Increase screening frequency to twice annually if any of the following develop 1:

• UACR >300 mg/g creatinine
• eGFR 30-60 mL/min/1.73 m²

Evaluation for Other Causes

At initial diagnosis, carefully assess for alternative causes of potential future kidney disease 1:

• Family history of polycystic kidney disease
• Chronic infections (HIV, hepatitis C)
• Autoimmune disorders (systemic lupus erythematosus, vasculitis)
• Malignancies (lymphoma, myeloma, solid tumors)
• History of acute kidney injury episodes
• Exposure to nephrotoxins

Important distinction: While diabetic kidney disease typically develops after >10 years in type 1 diabetes, it may be present at diagnosis in type 2 diabetes, making initial screening essential 1

Factors That Can Falsely Elevate UACR

Be aware that the following can transiently increase UACR without indicating kidney damage 1:

• Exercise within 24 hours
• Infection or fever
• Congestive heart failure
• Marked hyperglycemia
• Menstruation
• Marked hypertension