1. SHEFFIELD GUIDELINES: RENAL DISEASE IN DIABETES Dr Jenny Stephenson GP, Stannington Medical Centre 18.9.07

2. 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’.

3. 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

4. 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

5. 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

6. What the Guidelines Say (1) Definitions – Microalbuminuria is protein undetectable on Albustix, excreted at rate of 20- 200mcg/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

7. What the Guidelines Say (2) How to test for MA & patient advice sheet Managing Proteinuria flowchart Referral pointers and Primary Care work- up 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

8. 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.

9. 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.