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Diabetes, Advancing Chronic Kidney Disease Management Panel

Diabetes, Advancing Chronic Kidney Disease Management Panel

Test Summary

Diabetes, Advancing Chronic Kidney Disease Management Panel

  

Clinical Use

  • Monitor chronic kidney disease in patients with diabetic nephropathy

Clinical Background

Chronic kidney disease (CKD) due to diabetes occurs in 20% to 40% of patients and is the most common cause of end-stage renal disease.1 Both type 1 and type 2 diabetes patients are at risk. Throughout its early course, CKD has no symptoms. Symptoms appear as kidney damage slowly gets worse and may include fatigue and weakness, nausea and vomiting, swelling of feet and ankles, loss of appetite, and persistent itching. Metabolic bone disease characterized by hyperparathyroidism, hyperphosphatemia, and vitamin D deficiency is a common complication. This and other complications, such as acidosis, anemia, hypertension, and hypoalbuminemia, increase as kidney damage increases and the estimated glomerular filtration rate (eGFR) decreases.2

The Kidney Disease Improving Global Outcomes (KDIGO) guideline defines CKD as albuminuria ≥30 μg/mg creatinine or eGFR <60 mL/min/1.73m2 for >3 months.2 The American Diabetes Association (ADA) recommends screening for CKD using microalbumin testing beginning ≥5 years after diagnosis of type 1 diabetes and at diagnosis of type 2 diabetes.1 According to the ADA, testing for the complications of CKD should begin when the GFR is <60 mL/min/1.73m2 (Table 1).1 The KDIGO guideline recommends such testing when the GFR is <45 mL/min/1.73m2.2

Table 1. Monitoring Chronic Kidney Disease in Patients with Diabetesa

GFR (mL/min/1.73m2 )

Recommendation

Testing Frequency

Test

All patients

Yearly

Creatinine, microalbumin, potassium

45-60

Every 6 months

eGFR

Yearly or more often

Electrolyte panel, hemoglobin, calcium, phosphorus, PTH, 25-hydroxyvitamin D

30-44

Every 3 months

eGFR

Every 3 to 6 months

Electrolyte panel, hemoglobin, calcium, phosphorus, PTH, 25-hydroxyvitamin D, albumin, weight   

<30

 

Refer to a nephrologist

GFR, glomerular filtration rate; eGFR, estimated GFR; PTH, parathyroid hormone.
a Adapted from reference 1.

The Diabetes, Advancing Chronic Kidney Disease Management Panel includes the tests recommended for detection of most of the complications (Table 2). Such testing, combined with early treatment of the abnormalities identified, can slow the progression of kidney damage and associated complications.2 Components of the panel are listed in Table 2 and can be ordered separately.

Table 2. Individual Tests Included in the Diabetes, Advancing Chronic Kidney Disease Management Panela

Test Code

Test Name

Method

375

Creatinine with eGFR, Serum

Spectrophotometry

34392

Electrolyte Panel

Includes sodium (836), potassium (733), chloride (330), and carbon dioxide (310)

Ion selective electrode (Na+, K+, Cl -); spectrophotometry (CO2)

510(X)

Hemoglobin

Electronic cell sizing/counting/cytometry

6517

Microalbumin, Random Urine with Creatinine

Turbidimetry

718

Phosphate (as Phosphorus)

Spectrophotometry

8837

PTH, Intact and Calcium

Immunoassay (PTH); spectrophotometry  (Ca2+)

17306

Vitamin D, 25-Hydroxy, Total, Immunoassay

Immunoassay

a Components of the panel can be ordered separately.

Individuals Suitable for Testing

  • Individuals with type 1 or type 2 diabetes and eGFR <60 mL/min/1.73m2 or albuminuria ≥30 μg/mg creatinine2

Method

The method used for each component in the panel is shown in Table 2.

Interpretive Information

In patients with CKD, KDIGO guidelines recommend addressing complications when 1) carbon dioxide is <22 mmol/L (metabolic acidosis); 2) hemoglobin is <13.0 g/dL in males and <12.0 g/dL in females (anemia); and 3) markers of metabolic bone disease are abnormal ( phosphorus, PTH, vitamin D).2 A multifactorial treatment approach is required to overcome these complications (Table 3).

Table 3. Treatments for Complications of Chronic Kidney Disease in Patients with Diabetesa,2,3  

Complication

Therapeutic Target

Treatment Considerations

Acidosis

CO2 level within reference range

Bicarbonate supplement

Anemia

Hemoglobinb
   ≥12.0 g/dL (females >15 y)
   ≥13.0 g/dL (males >15 y)

Iron replacement; erythropoiesis-stimulating agent

Metabolic Bone Disease

 

 

    Hyperparathyroidism

Not established

Vitamin D supplements; calcimimeticsc (eg, cinacalcet); removal of the parathyroid glands

    Hyperphosphatemia

Phosphorus level within reference range

Phosphate binders; reduce dietary intake

    Vitamin D deficiency

25-hydroxyvitamin D
>30 ng/mL

Vitamin D supplements/analogs

a

The table is provided for informational purposes only and is not intended as medical advice. A physician’s test selection and interpretation, diagnosis, and patient management decisions should be based on his/her education, clinical expertise, and assessment of the patient.

b

See reference 2 for hemoglobin thresholds for children and pregnant women.

c

Calcimimetics suppress parathyroid hormone secretion.

References

  1. American Diabetes Association. Standards of medical care in diabetes—2017. Diabetes Care. 2017;40(suppl 1):S1-S120.

  2. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:1-150.

  3. National Institute of Diabetes and Digestive and Kidney Diseases. Mineral and bone disorder in chronic kidney disease. https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/mineral-bone-disorder. Updated November, 2015. Accessed January 23, 2017.
     

 Content reviewed 02/2017
 

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