## Type 2 Diabetes and Chronic Kidney Disease

### Table 1 Stages of Chronic Kidney Disease (CKD) and diagnostic levels

  ------------- ------------------ ------------------ -------- -------- ------------
                1                  2                  3        4        5

  eGFR\*        \> 60ml/min        \> 60ml/min        3 to 59  15 to 29 \<15ml/min
                                                      ml/min   ml/min   

  Proteinuria   microalbuminuria   macroalbuminuria                     
  ------------- ------------------ ------------------ -------- -------- ------------

\*Estimated Glomerular Filtration Rate

### Referrals

Make a referral to a Nephrologist when the eGFR is less than 60ml/min or
sooner if unsure of etiology of renal disease.

Make a referral to a Registered Dietitian (RD) for consultation on
protein, sodium (Na^+^), potassium (K^+^), phosphorus (PO~4~), fluids,
and saturated fat.

### Managing Complications of CKD in Stages 3 to 5

**Acidosis**

If the serum CO2 is less than 22mmol/L, start sodium bicarbonate 325 to
650mg; give 1to 2 tablets twice a day or QID. Goal is C0~2~ greater than
22mmol/L.

**Anemia**

**Check hemoglobin (Hb) at least yearly:** Anemia Hb less than 13.5 g/dL
adult men and less than 12 g/dL adult woman. Rule out other causes of
anemia such as B12 and folate deficiency, GI blood loss, and other
causes.

**Baseline Labs**: Ferritin, transferrin, percent saturation (% sat),
iron studies (Fe, % Sat, total iron binding capacity \[TIBC\]), and
complete blood count (CBC) with differential.

Start oral iron therapy if ferritin and/or iron studies find low values.

-   Ferrous Sulfate (FeSO~4~) 325mg daily to three times a day (TID).
    Consider docusate 100mg twice a day (TID) to reduce constipation.
    **Monitor ferritin levels to avoid iron overload**

-   Consider IV iron if needed (see iron protocol)

-   Consider erythorpoiesis stimulating agents (ESA) for Hb less than 10
    g/dL (see epo protocol). Dose ESA to maintain Hb between 10.5 and
    12mg/dL.

**Diabetes & Cardiovascular Disease (CVD)**

**Blood sugar control**---as renal function declines, a patient's blood
glucose often improve; titrate medications down as needed. 

**Discontinue (D/C) metformin when Creatinine is greater 1.5mg./dL in
men or greater than 1.4 mg/dL in women**. Insulin is usually the only or
main medication used to treat diabetes in patients with CKD.

**Peripheral Neuropathy**: Foot ulcers are common. Check patient's feet
each visit and refer as needed.

**Retinopathy**: Ophthalmology visits regularly to check for retinal
damage.

**Autonomic Neuropathy**: Frequent blood pressure fluctuations,
including orthostatic symptoms. 

**Hypertension (HTN):** BP goal is less than 130/80mmHg; continue ACE
Inhibitors or ARB; monitor serum K+ levels.

**CVD:** CKD increases CVD risk; give aspirin if there are no
contraindications. Achieve lipid targets and encourage tobacco
cessation.

**Edema/Fluid Overload**

Establish patient's dry weight.

Titrate furosemide as needed 20-240mg BID (diuresis lasts 6 hours; give
in the morning and at mid-day).

### Metabolic Bone Disease

**Phosphorus (PO~4~)**: if greater than 4.6 mg/dL, start binder
(calcium); Refer to RD for dietary PO~4~ restriction.

> **Calcium (Ca)**: target: 8.4 to 9.5 mg/dL
>
> If \< 8.4, start/increase calcium supplementation
>
> If \> 10.2, correct causes (often secondary to medications; need to
> hold Ca and/or Vitamin D or calcitriol
>
> **iPTH**: target level for Stage 3 is 35 to 70pg/mL; for  Stage 4 is
> 80 to 100pg/mL.
>
> If iPTH is elevated, measure 25(OH)D (Vitamin D)
>
> If 25(OH)D is equal to or greater than 30mg/mL, start calcitriol
>
> If 25(OH)D  \< 30mg/mL, start ergocalciferol (Vit D2)

Follow Ca, PO4, iPTH, and 25(OH)D (Vitamin D): if Ca or PO~4~ is above
target or if iPTH below target, hold calcitriol and/or calcium.

### Table 1. Stage of CKD and metabolic monitoring goals 

  --------- ---------- ------------ ------------ ------------ -----------------
  **CKD     **eGFR**   **iPTH       **PO~4~      **Ca goal**  **Ca X PO~4~**
  Stage**              goal**       goal**                    

  3         30-59      35-70        2.7-4.6      8.4-9.5      Less than 55

  4         15-29      80-100       2.7-4.6      8.4-9.5      Less than 55

  5         \< 15      150-300      3.5-5.5      8.4-9.5      Less than 55
  --------- ---------- ------------ ------------ ------------ -----------------

### Table 2. Phosphate binders\*, dose and effect on metabolic status

  ---------------- ----------------- ---------- ------------- ---------- ------------------
  **Medication**   **Dose**          **iPTH     **PO~4~       **Ca       **Comments**
                                     effect**   effect**      effect**   

  \*\*CaCO~3~      500-2000mg with   No change  Decrease      increase   Use if Ca less
  (Oyst-Cal or     meals (no more                                        than 8.4
  TUMS)            than 7g/d)                                            

  \*\*Ca Acetate   1334-2868mg with  No change  Significant   Increase   Use if Ca \< 8.4
                   meals                        decrease                 and PO~4~ \> 5

  \*\*Sevelamer    800-1600mg TID    No change  Significant   Increase   Decrease PO~4~, no
  (Renagel)                                     decrease                 effect on Ca

  \*\*Lanthanum    1500-3750mg/day   No change  Significant   Decrease   Decrease PO~4~ and
                   with meals                   decrease                 Ca^++^

  \*\*Aluminum     600-1200mg TID    No change  Significant   No change  ONLY if PO~4~ \> 7
                   between meals &              decrease                 and Ca x PO~4~ \>
                   bed time                                              55; not more than
                                                                         30 days
  ---------------- ----------------- ---------- ------------- ---------- ------------------

\*Always include dietary phosphorous restriction

### Table 3. Vitamin D and Analogs, dose and effect on metabolic status

+------------+----------+-------+---+--------+---------+-----------------+
| **Me       | **Dose** | *     | * |        | **Ca    | **Comments**    |
| dication** |          | *iPTH | * |        | e       |                 |
|            |          | eff   | P |        | ffect** |                 |
|            |          | ect** | O |        |         |                 |
|            |          |       | ~ |        |         |                 |
|            |          |       | 4 |        |         |                 |
|            |          |       | ~ |        |         |                 |
|            |          |       | e |        |         |                 |
|            |          |       | f |        |         |                 |
|            |          |       | f |        |         |                 |
|            |          |       | e |        |         |                 |
|            |          |       | c |        |         |                 |
|            |          |       | t |        |         |                 |
|            |          |       | * |        |         |                 |
|            |          |       | * |        |         |                 |
+------------+----------+-------+---+--------+---------+-----------------+
| \*Vit D~2~ | 1.25-5mg | Dec   |   | No     | Sign    | Use if Vit D    |
| (Ergoc     | daily    | rease |   | change | ificant | less than 30    |
| alciferol) |          |       |   |        | i       |                 |
|            |          |       |   |        | ncrease |                 |
+------------+----------+-------+---+--------+---------+-----------------+
| \*         | 0        | Dec   |   | No     | Sign    | Use only if Ca  |
| Calcitriol | .25-1mcg | rease |   | change | ificant | & PO~4~ in      |
|            | daily or |       |   |        | i       | normal range    |
|            | 0.5-3mcg |       |   |        | ncrease |                 |
|            | TIW      |       |   |        |         | Hold if Ca x    |
|            |          |       |   |        |         | PO~4~ greater   |
|            |          |       |   |        |         | than 55         |
+------------+----------+-------+---+--------+---------+-----------------+
| \*Doxer    | 0        | Dec   |   | No     | I       | Use only if Ca  |
| calciferol | .25-1mcg | rease |   | change | ncrease | & PO~4~ in      |
|            | daily or |       |   |        |         | normal range    |
|            | 0.5-3mcg |       |   |        |         |                 |
|            | TIW      |       |   |        |         | Hold if Ca x    |
|            |          |       |   |        |         | PO~4~ greater   |
|            |          |       |   |        |         | than 55         |
+------------+----------+-------+---+--------+---------+-----------------+

\*Drugs are [not]{.underline} on the IHS National Core Formulary

### Table 4. Other Medication

  -------------- ------------ ---------- ---------- ------------- ----------------
  Medication     Dose         iPTH       PO~4~      Ca effect     Comments
                              effect     effect                   

  \*Cinacalcet   30-180mg     Decrease   Decrease   Significant   Do not use if Ca
                 daily                              decrease      less than 8.4
  -------------- ------------ ---------- ---------- ------------- ----------------

\*Drugs are [not]{.underline} on the IHS National Core Formulary

### Table 5. Lab Monitoring for CKD

  --------------- -------- ------------------- ----------------- -----------------
  **Parameter**   **GFR \> **GFR 30-59**       **GFR 15-29**     **GFR \< 15 not
                  60**                                           on dialysis**

  Creatinine      Annual   Each visit          Each visit        Each visit

  eGFR            Annual   Each visit          Each visit        Each visit

  Hb              Annual   Every 3 to 4        Every 3t o 4      Every 3 to 4
                           months\*            months\*          months \*

  Serum iron               Every 3 to 4 months Every 3 to 4      Every 3 to 4
                                               months            months \*

  Transferrin              Every 3 months      Every 3 months    Every 3 months\*
  Saturation                                                     

  Ferritin                 Every 3 months      Every 3 months    Every 3 months

  iPTH                     At least annually\* Every 3 months \* Every 3 months \*

  Ca & PO~4~               At least annually\* Every 3 months \* Every month\*
  --------------- -------- ------------------- ----------------- -----------------

\* Monitor more often if on medications that affect these labs

**Reference:** KDOQI/NKF and UK Renal Assoc 4^th^ Ed. Clinical Practice
Guidelines for Complications of Chronic Kidney Disease