Transcript Document

SHEFFIELD GUIDELINES:
RENAL DISEASE IN DIABETES
Dr Jenny Stephenson
GP, Stannington Medical Centre
18.9.07
How to Access the Guidelines
• On Intranet, for both Primary and
Secondary Care
• From Primary Care, access is through the
PCT website –
• Select ‘Clinical Governance’ then ‘STH
and Citywide’, then ‘Diabetes – a
Resource Pack’.
eGFR’s
• Serum creatinine may not accurately
reflect kidney function
• Estimated Glomerular Filtration Rate
• Calculation based on the ‘Modification of
Diet in Renal Disease’ (MDRD) Formula:
using creatinine, sex, standard surface
area, and x1.21 if black
• Falsely lowered if person has high BMI
CKD Stages
• 1 - >90 + evidence of renal damage (eg
persistent proteinuria, haematuria, renal
structural abnormalities)
• 2 – 60-89 + evidence as above
• 3 – 30-59 (early renal insufficiency)
• 4 – 15-29 (late renal insufficiency)
• 5 - <15 (renal failure)
• In UK, prevalence is 6% in 50-75 with HBP; 13%
with DM, and 17% with both.
• It is an indicator for CVD
eGFR and Normal Ageing
• eGFR reduces by 6-10ml/min/1.73m² per
decade after 40 years
• Bear this in mind when interpreting eGFR
in the elderly
• 70 when they are 70; 60 or below (ie
‘CKD3’) when 80
What the Guidelines Say (1)
• Definitions – Microalbuminuria is protein
undetectable on Albustix, excreted at rate of 20200mcg/min or 30-300mg/day
• MA should be tested annually in all people with
T1DM who are Albustix negative (Micral test
strips now not recommended)
• MA does not directly correlate with early diabetic
renal disease in T2DM, but more with CVD risk.
Therefore current advice is not to test, but
address CVD risks
What the Guidelines Say (2)
• How to test for MA & patient advice sheet
• Managing Proteinuria flowchart
• Referral pointers and Primary Care workup before referral
• Which Clinic is appropriate (renal,
renal/diabetes, urology, gynaecology)
• Drug advice, eg no metformin (or fibrates)
if creatinine 150+, or eGFR under 60
eGFR and Metformin
• Lactic acidosis is the potential problem
• Rare (0.03 cases/1000 patient years) but
mortality is 50%
• Tissue hypoxia is main trigger rather than
accumulation of metformin (eg in HF, renal or
hepatic failure, respiratory failure, alcohol
intoxication, states of dehydration and fasting)
• Warn patients to stop Metformin for a few days if
dehydrated (eg D&V), planned operations etc.
To Minimise further Renal Decline:
• Optimise glycemic control
• Treat BP to 125/75
• Use ACE inhibitor (A2RB if side effects) to
max tolerated dose, even if not
hypertensive (beware hypotension!)
• Address general CVD risk by aiming for:
TC 3.5mmol/l or less, LDL <2.0; smoking
cessation, reduced central obesity; aspirin.