What is the next step in managing potential kidney issues?

Next Steps in Managing Potential Kidney Issues

Continue annual monitoring with quantitative assessment of urinary albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR), while optimizing glucose and blood pressure control. 1

Monitoring Schedule

For patients with diabetes and normal kidney function (eGFR ≥60 mL/min/1.73 m² and UACR <30 mg/g):

• Measure UACR and eGFR at least once annually 1
• Assess serum creatinine, potassium, and urinary albumin excretion yearly 1
• This applies to type 1 diabetes with duration ≥5 years and all type 2 diabetes patients 1

If eGFR drops to 45-60 mL/min/1.73 m²:

• Increase monitoring to every 6 months 1
• Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus, and parathyroid hormone at least yearly 1
• Consider dose adjustments for medications cleared by the kidneys 1

If eGFR drops to 30-44 mL/min/1.73 m²:

• Increase monitoring to every 3 months 1
• Monitor comprehensive metabolic panel every 3-6 months 1

When to Escalate Beyond Monitoring

Initiate ACE inhibitor or ARB therapy if:

• UACR rises to 30-299 mg/g (modestly elevated albuminuria) in the presence of hypertension 1, 2
• UACR ≥300 mg/g, regardless of blood pressure status 1
• Do NOT start these medications for primary prevention if blood pressure is normal and UACR <30 mg/g 1

When starting ACE inhibitors or ARBs:

• Monitor serum creatinine and potassium within 2-4 weeks after initiation 2, 3
• Continue therapy unless creatinine rises >30% within 4 weeks 2
• Expect and tolerate small increases in creatinine (up to 30%) as this represents hemodynamic changes, not kidney damage 2, 3

Referral Triggers to Nephrology

Refer promptly when:

• eGFR <30 mL/min/1.73 m² (stage 4 CKD or worse) 1
• Uncertainty about etiology of kidney disease (heavy proteinuria, active urine sediment, absence of retinopathy, rapid GFR decline) 1
• Difficult management issues: anemia, secondary hyperparathyroidism, resistant hypertension, or electrolyte disturbances 1
• Rapidly progressing kidney disease (rapid decline in eGFR) 1
• UACR ≥300 mg/g with eGFR <60 mL/min/1.73 m² 4, 5

Optimize Risk Factors During Monitoring

Blood pressure control:

• Target <140/90 mmHg generally; consider <130/80 mmHg for select patients 1
• This reduces both cardiovascular disease mortality and slows CKD progression 1

Glycemic control:

• Intensive diabetes management delays onset and slows progression of diabetic kidney disease 1
• Certain diabetes medications (empagliflozin, canagliflozin, liraglutide, semaglutide) have demonstrated kidney protective effects beyond glucose control 1

Avoid nephrotoxins:

• Review and limit over-the-counter medicines, NSAIDs, and herbal remedies 1, 4
• Adjust dosing of medications cleared by kidneys 1

Common Pitfalls to Avoid

• Do not delay monitoring: Even with normal baseline kidney function, annual screening is essential as up to 40% of diabetes patients develop kidney disease 1
• Do not withhold ACE inhibitors/ARBs due to mild creatinine elevation: Increases up to 30% are expected and acceptable 2, 3
• Do not use dual RAAS blockade: Combining ACE inhibitor with ARB increases adverse events without additional benefit 2
• Do not restrict dietary protein below 0.8 g/kg/day: This does not alter outcomes and is not recommended 1
• Do not ignore spontaneous remission: Up to 40% of patients with UACR 30-299 mg/g may experience spontaneous remission, so continued monitoring assesses disease trajectory 1