Chronic Kidney Disease in Diabetes

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Philip McFarlane MD, FRCPC Richard E. Gilbert MBBS, PhD, FACP, FRACP, FRCPC Lori MacCallum BScPhm, PharmD Peter Senior MBBS, PhD, MRCP

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Identification of chronic kidney disease (CKD) in diabetes requires screening for proteinuria, as well as an assessment of renal function.
  • All individuals with CKD should be considered at high risk for cardiovascular events and should be treated to reduce these risks.
  • The progression of renal damage in diabetes can be slowed through intensive glycemic control and optimization of blood pressure. Progression of diabetic nephropathy can be slowed through the use of medications that disrupt the renin-angiotensin-aldosterone system.

Highlights of Revisions

  • The chapter includes a new, simplified definition of microalbuminuria of albumin to creatinine ratio (ACR) ≥2.0 mg/mmol for both men and women (Table 1 and Table 2).
  • The chapter includes a new algorithm for screening for chronic kidney disease in adults (Figure 1).
  • Added a "Sick Day Management" list for acute illness (p. S357).

Practical Tips

Management of Potassium and Creatinine During the Use of Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin II Receptor Blocker (ARB) or Direct Renin Inhibitor (DRI)

  • Check serum potassium and creatinine at baseline and within 1 to 2 weeks of initiation or titration of therapy AND during times of acute illness.
  • If potassium becomes elevated or creatinine increases by more than 30% from baseline, therapy should be reviewed and serum creatinine and potassium levels should be rechecked.
  • Mild-to-moderate stable hyperkalemia:
    • Counsel on a low-potassium diet.
    • If persistent, non–potassium-sparing diuretics and/or oral sodium bicarbonate (in those with a metabolic acidosis) should be considered.
    • Consider temporarily holding renin-angiotensin-aldosterone system (RAAS) blockade (i.e. ACE inhibitor, ARB or DRI).
  • Severe hyperkalemia:
    • In addition to emergency management strategies, RAAS blockade should be held or discontinued.
Table 1
Stages of diabetic nephropathy by level of urinary albumin level
Table 2
Conditions that can cause transient albuminuria

Figure 1
Screening for chronic kidney disease (CKD) in people with diabetes. Please note, Table 4 listed in the above figure can be viewed in the full 2013 guidelines.


  1. 1. In adults, screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR [Grade D, Consensus]. Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and 5 years after diagnosis in adults with type 1 diabetes and repeated yearly thereafter. A diagnosis of CKD should be made in patients with a random urine ACR ≥2.0 mg/mmol and/or an eGFR<60 mL/min on at least 2 of 3 samples over a 3-month period [Grade D, Consensus].
  2. 2. All patients with diabetes and CKD should receive a comprehensive, multifaceted approach to reduce cardiovascular risk (see Vascular Protection, p. S100) [Grade A, Level 1A (1,2)].
  3. 3. Adults with diabetes and CKD with either hypertension or albuminuria should receive an ACE inhibitor or an ARB to delay progression of CKD [Grade A, Level 1A for ACE inhibitor use in type 1 and type 2 diabetes, and for ARB use in type 2 diabetes; Grade D, Consensus, for ARB use in type 1 diabetes (3–12) ].
  4. 4. People with diabetes on an ACE inhibitor or an ARB should have their serum creatinine and potassium levels checked at baseline and within 1 to 2 weeks of initiation or titration of therapy and during times of acute illness [Grade D, Consensus].
  5. 5. Adults with diabetes and CKD should be given a “sick day” medication list that outlines which medications should be held during times of acute illness (see Appendix 7 ) [Grade D, Consensus].
  6. 6. Combination of agents that block the renin-angiotensin-aldosterone system (ACE inhibitor, ARB, DRI) should not be routinely used in the management of diabetes and CKD [Grade A, Level 1 (13,14) ].
  7. 7. People with diabetes should be referred to a nephrologist or internist with an expertise in CKD in the following situations:
    1. a. Chronic, progressive loss of kidney function
    2. b. ACR persistently >60 mg/mmol
    3. c. eGFR<30 mL/min
    4. d. Unable to remain on renal-protective therapies due to adverse effects such as hyperkalemia or >30% increase in serum creatinine within 3 months of starting an ACE inhibitor or ARB
    5. e. Unable to achieve target BP (could be referred to any specialist in hypertension) [Grade D, Consensus]

ACE , angiotensin-converting enzyme; ACR , albumin-to-creatinine ratio; ARB , angiotensin II receptor block; CKD , chronic kidney disease; DRI , direct renin inhibitor.


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Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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