Kidney Damage

Detection and surveillance

Raised albumin excretion rate in Type 2 diabetes is often a sign of general vascular damage rather than specific renal damage. It is a useful arterial risk marker

Abnormal serum creatinine in Type 2 dIabetes IS often due to renal arterial disease and/or
diuretic therapy for cardiac failure rather than to diabetic nephropathy

Detection and surveillance of specific kidney problems therefore depends on identifying progression of albumin excretion rate and serum creatinine, in the absence of other causes

Check for proteinuria yearly using reagent strips

Measure urinary albumin excretion yearly (if not proteinuric) using:

pre-breakfast albumin:creatinine ratio, or

pre-breakfast urinary albumin concentration

ratio >2.5 mg/mmol (>30 mg/g) in men or >3.5 mg/mmol (>40 mg/g) in women

concentration >20 mg/I:

Repeat to confirm
Monitor progression of kidney damage by more frequent measurement

Check for infection and consider other renal disease if proteinuna positive

exclude infection with leucocyte/nitrate strips and microscopy / culture if positive

Measure serum creatinine yearly ( more often if abnormal, or if rising and metformin-treated )

Measure blood pressure yearly for surveillance purposes ( sitting, after 5 min rest, 1st/5th phase )

Management if raised albumin excretion rate

If serum creatinine normal:
	monitor albumin excretion rate yearly to detect progression suggestive ot specific diabetic kidney damage
	intensify management of modifiable arterial risk factors (glucose, lipids, blood pressure)
If serum creatinine abnormal:
	review other possible causes of renal impairment ( recurrent infection, renal arterial I hypertensive damage, loop diuretic therapy / cardiac failure, glomerulonephritis)
	monitor albumin excretion and serum creatinine more frequently to detect progression of renal damage
If specific diabetic kidney damage (diabetic nephropathy) suspected:
	treat blood pressure aggressively with a target of <130/80 mmHg
		reduce salt intake
		use ACE-inhibitors as first-line drug therapy
		add loop diuretics, other agents if necessary
	reduce protein intake with target of <0.8 g/kg
	maintain good blood glucose control and tight arterial risk factor control (see above)
	treat urinary infections aggressively; consider papillary necrosis if recurrent
	arrange evaluation by a nephrologist before creatinine rises to 250 ľmol/l (3.0 mg/dl)

Eye Damage