Managing chronic kidney disease in type 2 diabetes in family practice.

Diabetic nephropathy is the leading cause of stage 5 chronic kidney disease (CKD) and occurs in 1 in 9 persons with newly diagnosed type 2 diabetes. Screening should begin at the time of type 2 diabetes diagnosis to detect the presence of a decreased estimated glomerular filtration rate (GFR) and/or an elevated albumin excretion rate. The estimated GFR can be used to stage CKD, assess cardiovascular risk, and develop treatment strategies. A multifaceted treatment plan delivered using a collaborative care approach that fosters person self-management is important. Glucose-lowering agents should be selected based on renal function and titrated to achieve an A1c less than 7.0%. Lipid-lowering therapy with a statin should be utilized to achieve a low-density lipoprotein cholesterol less than 100 mg/dL, possibly less than 70 mg/dL. An angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or direct renin inhibitor, typically in combination with other antihypertensive therapies, is recommended for persons with hypertension, microalbuminuria/macroalbuminuria, and type 2 diabetes, as this approach has been shown to be renoprotective. Angiotensin-converting inhibitors have an additional benefit of improving cardiovascular outcomes in CKD.