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Stages of diabetic nephropathy

Authoring team

Diabetic nephropathy can be classified into normal, microalbuminuria, macroproteinuria and endstage renal disease, according to the amount of albumin excreted. Albumin excretion should be measured on 3-4 samples before persistent microabuminuria is declared to be present as there is often a diurnal variation in excretion of upto 40%. It should also be noted that there is a relationship between the blood pressure and level of proteinuria.

 

STAGE

Normal

Micro

Macro

End Stage Renal Disease (ESRD)

albumin excretion (mg/l)

<20

20-200

>200

>1000

blood pressure

120/75

130/85

145/95

160/100

GFR (ml/min)

>110

>110

<100

<30

Patients with microalbuminuria often have associated problems of hypertension, left ventricular hypertrophy and insulin resistance.

Patients that develop frank proteinuria are a group that have more problems and appear to have more aggressive disease and particularly have problems with macrovascular disease with an increased mortality.

NICE suggest (1):

  • clinicians should use urine albumin:creatinine ratio (ACR) in preference to protein:creatinine ration (PCR) in order to detect proteinuria
    • ACR has greater sensitivity than protein:creatinine ratio (PCR) for low levels of proteinuria. For quantification and monitoring of proteinuria, PCR can be used as an alternative. ACR is the recommended method for people with diabetes
    • for the initial detection of proteinuria, if the ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a subsequent early morning sample. If the initial ACR is 70 mg/mmol or more, a repeat sample need not be tested
    • regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria
    • quantify urinary albumin or urinary protein loss for:
      • people with diabetes
      • people without diabetes with a GFR of less than 60 ml/min/1.73 m^2
  • NICE suggested a classification of CKD incorporating GFR and ACR (1)

ACR (albumin creatinine ratio) category

ACR (mg/mmol)

A1

<3

A2

3-30*

A3

>30**

  • * Relative to young adult level
  • ** Including nephrotic syndrome (ACR usually >220 mg/mmol)
  • CKD is classified according to estimated GFR (eGFR) and albumin:creatinine ratio (ACR), using 'G' to denote the GFR category (G1-G5, which have the same GFR thresholds as the CKD stages 1-5 recommended previously) and 'A' for the ACR category (A1-A3), for example:
    • a person with an eGFR of 25 ml/min/1.73 m2 and an ACR of 15 mg/mmol has CKD G4A2.
    • a person with an eGFR of 50 ml/min/1.73 m2 and an ACR of 35 mg/mmol has CKD G3aA3
    • an eGFR of less than 15 ml/min/1.73 m2 (GFR category G5) is referred to as kidney failure
    • it is noted that:
      • increased ACR is associated with increased risk of adverse outcomes
      • decreased GFR is associated with increased risk of adverse outcomes
      • increased ACR and decreased GFR in combination multiply the risk of adverse outcomes

This is summarised as (2):

 

Abbreviations: ACR, albumin:creatinine ratio; CKD, chronic kidney disease

Notes:

  • consider using eGFRcystatinC at initial diagnosis to confirm or rule out CKD in people with:
    • an eGFRcreatinine of 45-59 ml/min/1.73 m2, sustained for at least 90 days and
    • no proteinuria (albumin:creatinine ratio [ACR] less than 3 mg/mmol) or other marker of kidney disease
  • do not diagnose CKD in people with:
    • an eGFRcreatinine of 45-59 ml/min/1.73 m2 and
    • an eGFRcystatinC of more than 60 ml/min/1.73 m2 and
    • no other marker of kidney disease
  • use of renin-angiotensin system antagonist to people with CKD based on ACR:
    • angiotensin-converting enzyme inhibitors (ACE inhibitors)/ angiotensin-II receptor blockers (ARBs) should be offered to non-diabetic people with CKD:
      • diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)
      • hypertension and an ACR of 30 mg/mmol or more (ACR category A3)
      • an ACR of 70 mg/mmol or more (irrespective of hypertension or cardiovascular disease)

Reference:


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