Pathways and Stages Kidney disease pathway hematuria pathway diabetes pathway non-diabetic MRP CKD stages referral sheet
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Diabetic Nephropathy Management Guidelines

Diabetic Nephropathy Management Guidelines

To be used concomitantly with Kidney Disease Referral Pathway

RETURN to the Kidney Disease Referral Pathway

Guidelines for using ACE-I and ARB:

  • ACE-I/ARB are absolutely contraindicated in pregnancy. Any pre-menopausal woman on and ACE-I /ARB should be on an appropriate contraceptive method.
  • Always check eGFR and serum K prior to and in 1-2 weeks of initiation or increasing dose of ACE-I/ARB.
  • Expect up to a 15% decrease in eGFR. If eGFR decreases repeat again in 1-2 weeks and If eGFR decrease is stable continue ACE-I/ARB; if not, repeat eGFR again in 1-2 weeks. If eGFR continues to decrease, STOP ACE-I/ARB.
  • IF serum K >6 advise dietary K restriction +/- prescribe diuretic if tolerated, +/- prescribe K resin binder. If unsuccessful in lowering serum K to ≤ 5.5, DECREASE OR STOP ACE-I/ARB,
  • HOLD ACE-I/ARB if patient has severe vomiting/diarrhea, or volume depletion

Interventions and Targets for Diabetic Nephropathy:

  • Regular exercise program.
  • Weight loss if obesity.
  • Cessation of smoking
  • Low Sodium Diet (Advise check food labels)
  • Avoid NSAIDS & other nephrotoxins
  • Target BP < 130/80
  • Target HgbA1C < 7% (check Q 3 mos)
  • Target LDL < 2 mmol/l, TC/HDL < 4.0
  • Consider prescribing ASA.
  • Assess medications for potential contraindication in CKD.
  • Adjust medication dosing for level of eGFR
  • Discontinue metformin for eGFR ≤ 30. Use with caution or discontinue for eGFR < 60.
  • Monitor glucose closely and consider stopping long acting sulfanylurea (eg glyburide) in patients with declining eGFR.
If ACR > 3 mg/mmol (on 2/3 specimens)

  • ⇒ YES
  • ⇒ NO
Screen annually

Start ACE-I or ARB (unless eGFR < 30 or BP <110/70) Repeat ACR in 4-6 weeks

  • ⇒ Next
Is ACR < 3 mg/mmol or reduced ≥ 50%

  • ⇒ YES
  • ⇒ NO
Increase dose of ACE-I or ARB

BP < 130/80?

  • ⇒ YES
  • ⇒ NO
Check BP Q 3 mos. Repeat blood and urine tests at intervals per Kidney Disease Referral Pathway

Increase dose of ACE-I/ARB and/or add thiazide diuretic

  • ⇒ Next
BP <130/80 4-6 weeks later?

  • ⇒ YES
  • ⇒ NO
Add CCB and titrate to max tolerated dose and if required add other meds such as B-Blocker or alpha blockers to achieve target.

  • ⇒ Next
Consider consult to Hypertension clinic or Nephrology if target not achieved when patient is on 4 medications or on 3 but intolerant of others. Elective.