Diabetic nephropathy Diagnosis and management Urinary albumin testing Q Does the patient have T1DM of 5 years duration? Q Does the patient have T2DM? Q Does the patient have diabetes with comorbid hypertension? No to all Consider alternative diagnoses. Yes to any Yes to any No to all Assess urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR at least annually in all patients with T2DM regardless of treatment. B Monitor urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR 1-4 times per year depending on the stage of the disease in patients with established diabetic kidney disease. B Primary prevention RAAS blockers Q Does the patient have a normal BP? Q Does the patient have a normal urinary albumin-to-creatinine ratio (<30 mg/g creatinine)? Q Does the patient have a normal eGFR? Yes to all Do not use ACEIs or ARBs for the primary prevention of CKD in patients with diabetes with normal BP, normal urinary albumin-to-creatinine ratio (< 30 mg/g creatinine), and normal eGFR. D Primary prevention (glycemic control) Optimize glucose control to reduce the risk of CKD. A Primary prevention (blood pressure control) Optimize BP control and reduce BP variability to reduce the risk or slow the progression of CKD. A No to any Do not use ACEIs or ARBs for the primary prevention of CKD in patients with diabetes with normal BP, normal urinary albumin-to-creatinine ratio (< 30 mg/g creatinine), and normal eGFR. D Initiate either ACEIs or ARBs in nonpregnant patients with diabetes and hypertension with severely increased albuminuria (urinary albumin-to-creatinine ratio 300 mg/g creatinine) and/or eGFR < 60 mL/min/1.73 m . A Consider initiating ACEIs or ARBs in nonpregnant patients with diabetes and hypertension with moderately increased albuminuria (urinary albumin-to-creatinine ratio 30-299 mg/g creatinine). C Monitor serum creatinine and potassium levels periodically for the development of increased creatinine or changes in potassium when ACEIs, ARBs, or mineralocorticoid receptor antagonists are used, or hypokalemia when diuretics are used. B Do not discontinue RAAS blockade for increases in serum creatinine ( 30%) in the absence of volume depletion. D Initiate a nonsteroidal mineralocorticoid receptor antagonist (finerenone) to reduce CKD progression and cardiovascular events in patients with CKD and albuminuria at increased risk for cardiovascular events or CKD progression. A Blood pressure control Optimize BP control and reduce BP variability to reduce the risk or slow the progression of CKD. A Glycemic control Optimize glucose control to slow the progression of CKD. A Dietary protein intake Aim to a target level of 0.8 g/kg body weight/day of dietary protein intake in patients with nondialysis-dependent stage 3 CKD. A Consider allowing higher levels of dietary protein intake in patients on dialysis since protein energy wasting is a major problem in some patients on dialysis. B Indications for specialist referral Q Does the patient have an eGFR < 30 mL/min/1.73 m ? Yes Refer patients for evaluation by a nephrologist if urinary albumin levels are continuously increasing and/or eGFR is continuously decreasing or is < 30 mL/min/1.73 m . A Refer patients promptly to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. A No Serial laboratory monitoring Q Is the patient being treated with an ACEI, ARB, or diuretic? Yes Monitor serum creatinine and potassium levels periodically for the development of increased creatinine or changes in potassium when ACEIs, ARBs, or mineralocorticoid receptor antagonists are used, or hypokalemia when diuretics are used. B No Continue management and follow-up as clinically appropriate.